Critical limb ischemia (CLI) is a highly morbid disease with many patients considered poor surgical candidates. The lack of treatment options for CLI has driven interest in developing molecular therapies within recent years. Through these translational medicine studies in CLI, much has been learned about the pathophysiology of the disease. Here, we present an overview of the macrovascular and microvascular changes that lead to the development of CLI, including impairment of angiogenesis, vasculogenesis, and arteriogenesis. We summarize the randomized clinical controlled trials that have used molecular therapies in CLI, and discuss the novel imaging modalities being developed to assess the efficacy of these therapies.
NehlerMRDuvalSDiaoL. Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population. J Vasc Surg. 2014;60(3):686–695.e682. doi:10.1016/j.jvs.2014.03.290
3.
CaroJMigliaccio-WalleKIshakKJProskorovskyI. The morbidity and mortality following a diagnosis of peripheral arterial disease: long-term follow-up of a large database. BMC Cardiovasc Disord. 2005;5. doi:10.1186/1471-2261-5-14
4.
TeraaMConteMSMollFLVerhaarMC. Critical limb ischemia: current trends and future directions. J Am Heart Assoc. 2016;14:63–74. doi:10.2147/VHRM.S125065
5.
SprengersRWTeraaMde WitGA. Quality of life in patients with no-option critical limb ischemia underlines the need for new effective treatment. J Vas Surg. 2010;52(4):843–849. doi:10.1016/j.jvs.2010.04.057
6.
IyerSRAnnexBH. Therapeutic angiogenesis for peripheral artery disease: lessons learned in translational science. JACC Basic Transl Sci. 2017;2(5):503–512. doi:10.1016/j.jacbts.2017.07.012
7.
GorenoiVBrehmMUKochAHagenA. Growth factors for angiogenesis in peripheral arterial disease. Cochrane Database Syst Rev. doi:10.1002/14651858.CD011741.pub2
8.
HammerASteinerS. Gene therapy for therapeutic angiogenesis in peripheral arterial dsiease—a systemic review and meta-analysis of radnomized, controlled trials. Vasa. 2013;42(5):31–39. doi:10.1024/0301-1526/a000298
9.
MiaoYLWuWLiBW. Clinical effectiveness of gene therapy on critical limb ischemia. Vasc Endovascular Surg. 2014;48(5-6):372–377. doi:10.1177/1538574414539397
10.
RigatoMMonamiMFadiniGP. Autologous cell therapy for peripheral arterial disease: systematic review and meta-analysis of randomized, nonrandomized, and noncontrolled studies. Circ Res. 2017;120(8):1326–1340. doi:10.1161/CIRCRESAHA.116.309045
CoatsPWadsworthR. Marriage of resistance and conduit arteries breeds critical limb ischemia. Am J Physiol Heart Circ Physiol. 2004;288(3):H1044–H1050. doi:10.1152/ajpheart.00773.2004
13.
LoweG. Pathophysiology of Critical Ischaemia. Berlin, Germany: Springer-Verlag; 1990: 21–32.
14.
HiattWR. Pathophysiology of Peripheral Artery Disease, Intermittent Claudication, and Critical Limb Ischemia. 2nd ed. Amsterdam, the Netherlands: Elsevier; 2012: 223–230.
15.
KawanoHMotoyamaTHiraiNKugiyamaKYasueHOgawaH. Endothelial dysfunction in hyperchoelsterolemia is improved by L-arginine admnistration: possible role of oxidative stress. Atherosclerosis. 2002;161(2):375–380. doi:10.1016/S0021-9150(01)00671-2
16.
YatacoARCorrettiMCGardnerAWWomackCJKatzelLI. Endothelial reactivity and cardiac risk factors in older patients with peripheral arterial disease. Am J Cardiol. 1999;83(5):754–758.
17.
BrevettiGMartoneVDde CristofaroT. High levels of adhesion molecules are associated with impaired endothelium-dependent vasodilation in patients with peripheral arterial disease. Thromb Haemost. 2001;85(1):63–66.
18.
DinennoFATanakaHMonahanKD. Regular endurance exercise induces expansive arterail remodelling in trained limbs of healthy men. J Physiol. 2001;534(pt 1):287–295. doi:10.1111/j.1469-7793.2001.00287.x
19.
DelpMDColleranPNWilkersonMK. Structural and functional remodeling of skeletal muscle microvasculature is induced by simulated microgravity. Am J Physiol Heart Circ Physiol. 2000;278(6):H1866–H1873. doi:10.1152/ajpheart.2000.278.6.H1866
20.
PowellRJGoodneyPMendelsohnFO. Safety and efficacy of patient specific intramuscular injection of HGF plasmid gene therapy on limb perfusion and wound healing in patients with ischemic lower extremity ulceration: results of the HGF-0205 trial. J Vasc Surg. 2010;52(6):1525–1530. doi:10.1016/j.jvs.2010.07.044
21.
AbhinandCSRajuRSoumyaSJAryaPSSudhakaranPR. VEGF-A/VEGFR2 signaling network in endothelial cells relevant to angiogenesis. J Cell Commun Signal. 2016;10(4):347–354. doi:10.1007/s12079-016-0352-8
22.
TuomistoTTRissanenTTVajantoIKorkeelaARutanenJYlä-HerttualaS. HIF-VEGF-VEGFR-2, TNF-a and IGF pathways are upregulated in critical human skeletal muscle ischemia as studied with DNA array. Atherosclerosis. 2004;174(1):111–120. doi:10.1016/j.atherosclerosis.2004.01.015
23.
NambaTKoikeHMurakamiK. Angigogenesis induced by ednothelial nitric oxide synthase gene through vascular endothelial growth factor expression in a rat hindlimb ischemia model. Circulation. 2003;108(18):2250–2257. doi:10.1161/01.CIR.0000093190.53478.78
24.
CouffnihalTSilverMKearneyM. Impaired collateral vessel development associatd with reduced expression of vascular endothelial growth factor in ApoE-/- mice. Circulation. 1999;99(24):3188–3198. doi:10.1161/01.CIR.99.24.3188
25.
MinistroAde OliveiraPNunesRJ. Low-dose ionizing radiation induces therapeutic neovascularization in a pre-clinical model of hindlimb ischemia. Cardiovasc Res. 2017;113(7):783–794. doi:10.1093/cvr/cvx065
26.
KakinumaYFurihataMAkiyamaT. Donepezil, an acetylcholinesterase inhibitor against Alzheimer’s dementia, promotes angiogenesis in an ischemic hindlimb model. J Mol Cell Cardiol. 2010;48(4):680–693. doi:10.1016/j.yjmcc.2009.11.010
27.
ChoksySPockleyAGWajehYEChanP. VEGF and VEGF receptor expression in human chronic critical limb ischaemia. Eur J Vasc Endovasc Surg. 2004;28(6):660–669. doi:10.1016/j.ejvs.2004.09.001
28.
JalkanenJMaksimowMHollménMJalkanenSHakovirtaH. Compared to intermittent claudication critical limb ischemia is associated with elevated levels of cytokines. PLoS One. 2016;11(9). doi:10.1371/journal.pone.0162353
29.
BaczynskaDMichalowskaDBarcPSkoraJKarczewskiMSadakierska-ChudyA. The expression profile of angiogenic genes in critical limb ischemia popliteal arteries. J Physiol Pharmacol. 2016;67(3):353–362.
30.
InoueMItohHUedaM. Vascular endothelial growth factor (VEGF) expression in human coronary atherosclerotic lesions. Criculation. 1998;98(20):2108–2116.
31.
BledaSDe HaroJVarelaCEsparzaLDe MaturanaILAcinF. Impact of VEGF polymorphisms on the severity of peripheral artery disease in diabetic patients. Growth Factors. 2012;30(5):277–282.
32.
BaumgartnerIPieczekAManorO. Constitutive expression of phVEGF165 after intramuscular gene transfer promotes collateral vessel development in patients with critical limb ischemia. Circulation. 1998;97(12):1114–1123. doi:10.1161/01.CIR.97.12.1114
33.
KusumantoYHvan WeelVMulderNH. Treatment with intramuscular vascular endothelial growth factor gene compared with placebo for patients with diabetes mellitus and critical limb ischemia: a double-blind randomized trial. Hum Gene Ther. 2006;17(6):683–691. doi:10.1089/hum.2006.17.683
34.
MorishitaRAokiMYoYOgiharaT. Hepatocyte growth factor as cardiovscular hormone: role of HGF in the pathogenesis of cardiovascular disease. Endocr J. 2001;49(3):273–284.
35.
OdaMTobaKKatoK. Hypocellularity and insufficient expression of angiogenic factors in implanted autologous bone marrow in patients with chronic critical limb ischemia. Heart Vessels. 2012;27(1):38–45.
36.
MorishitaRNakamuraSHayashiS. Therapeutic angiogenesis induced by human recombinant hepatocyte growth factor in rabbit hind limb ischemia model as cytokine supplement therapy. Hypertension. 1999;33(6):1379–1384.
37.
YamamotoYMatsuuraTNarazakiG. Synergistic effects of autologous cell and hepatocyte growth factor gene therapy for neovascularization in a murine model of hindlimb ischemia. Am J Physiol Heart Circ Physiol. 2009;297(4):H1329–H1336. doi:10.1152/ajpheart.00321.2009
38.
SigematsuHYasudaKIwaiT. Randomized, double-blind, placebo-controlled clinical trial of hepatocyte growth factor plasmid for critical limb ischemia. Gene Ther. 2010;17(9):1152–1161. doi:10.1038/gt.2010.51
39.
PowellRJSimonsMMendelsohnFO. Results of a dobe-blind, placebo-controlled study to assess the safety of intramuscular injection of hepatocyte growth factor plasmid to improve limb perfusion in patients with critical limb ischemia. Circulation. 2008;118(1):58–65. doi:10.1161/CIRCULATIONAHA.107.727347
OnimaruMYonemitusYTaniiM. Fibroblast growth factor-2 gene transfer can stimulate hepatocyte growth factor expression irrespective of hypoxia-mediated downregulation in ischemic limbs. Circ Res. 2002;91(10):923–930.
42.
JalkanenJHauteroOMaksimowMJalkanenSHakovirtaH. Correlation between increasing tissue ischemia and circulating levels of angiogneic growth factors in peripheral artery disease. Cytokine. 2018;110:24–28.
43.
HorioTFujitaMTanakaY. Efficacy of fragmin/protamine microparticles containing fibroblast growth factor-2 (F/P MPs/FGF-2) to induce collateral vessels in a rabbit model of hindlimb ischemia. J Vasc Surg. 2011;54(3):791–798. doi:10.1016/j.jvs.2011.02.060
44.
NikolSBaumgartnerIVan BelleE. Therapeutic angiogenesis with intramuscular NV1FGF improves amputation-free survival in patients with critical limb ischemia. Mol Ther. 2008;16(5):972–978. doi:10.1038/mt.2008.33
45.
BelchJHiattWRBaumgartnerI. Effect of fibroblast growth factor NV1FGF on amputation and death: a randomised placebo-controlled trial of gene therapy in critical limb ischemia. Lancet. 2011;377(9781):1929–1937.
46.
LeuSDayYJSunCKYipHK. tPA-MMP-9 axis plays a pivotal role in mobilization of endothelial progenitor cells from bone marrow to circulation and ischemic region for angiogenesis. Stem Cells Int. 2016;2016:5417565. doi:10.1155/2016/541756
47.
YipHKSunCKTsaiTH. Tissue plasminogen activator enhances mobilization of endothelial progenitor cells and angiogenesis in murine limb ischemia. Int J Cardiol. 2013;168(1):226–236. doi:10.1016/j.ijcard.2012.09.090
48.
TeraaMSprengersRWWesterweelPE. Bone marrow alterations and lower endothelial progenitor cell numbers in critical limb ischemia patients. PLoS One. 2013;8(1). doi:10.1371/journal.pone.0055592
49.
DopheideJFGeisslerPRubrechJ. Inflammation is associated with a reduced number of pro-angiogenic Tie-2 monocytes and endothelial progenitor cells in patients with critical limb ischemia. Angiogenesis. 2016;19(1):67–78. doi:10.1007/s10456-015-9489-y
50.
Di StefanoRBarsottiMCMelilloE. The prostacyclin analogue iloprost increases circulating endothelial progenitor cells in patients with critical limb ischemia. Thromb Haemost. 2008;100(5):871–877.
51.
LosordoDWKibbeMRMendelsohnF. A randomized, controlled pilot study of autologous CD34+ cell therpay for critical limb ischemia. Circ Cardiovasc Interv. 2012;5(6):821–830. doi:10.1161/CIRCINTERVENTIONS.112.968321
52.
LiottaFAnnunziatoFCastellaniS. Therapeutic efficacy of autologous non-mobilized enriched circulating endothelial progenitors in patients with critical limb ischemia: the SCELTA trial. Circ J. 2018;82(6):1688–1698.
53.
LuDChenBLiangZ. Comparison of bone marrow mesenchymal stem cells with bone marrow-derived mononuclear cells for treatment of diabetic critical limb ischemia and foot ulcer: a double-blind, randomized, controlled trial. Diabetes Res Clin Pract. 2011;92(1):26–36. doi:10.1016/j.diabres.2010.12.010
54.
DeindlESchaperW. The art of arteriogenesis. Cell Biochem Biophys. 2005;43(1):1–15. doi:10.1385/CBB:43:1:001
55.
PatelASSmithANuceraS. TIE2-expressing monocytes/macrophages regulate revascularization of the ischemic limb. EMBO Mol Med. 2013;5(6):858–869. doi:10.1002/emmm.201302752
56.
MagriDVasilasPMutoA. Elevated monocytes in patients with critical limb ischemia diminish after bypass surgery. J Surg Res. 2011;167(1):140–150. doi:10.1016/j.jss.2009.06.014
57.
Tateishi-YuyamaEMatsubaraHMuroharaT. Therapeutic angiogenesis for patients with limb ischaemia by autologous transplantation of bone-marrow cells: a pilot study and a randomised controlled trial. Lancet. 2002;360(9331):427–435. doi:10.1016/S0140-6736(02)09670-8
58.
DarADomevHBen-YosefO. Multipotent vasculogenic pericytes from human pluripotent stem cells promote recovery of murine ischemic limb. Circulation. 2011;125(1):87–99.
59.
MacAskillMGSaifJCondieA. Robust revascularization in models of limb ischemia using a clinically translatable human stem cell-derived endothelial cell product. Mol Ther. 2018;26(7):1669–1684.
60.
StacyMRSinusasAJ. Novel applications of radionuclide imaging in peripheral vascular disease. Cardiol Clin. 2016;34(1):167–177. doi:10.1016/j.ccl.2015.06.005
61.
MilesKABarberRWWraightEPCooperMAppletonDS. Leg muscle scintigraphy with 99Tcm-MIBI in the assessment of peripheral vascular (arterial) disease. Nucl Med Commun. 1992;13(8):593–603.
62.
MiyamotoMYasutakeMTakanoH. Therapeutic angiogenesis by autologous bone marrow cell implantation for refractory chronic peripheral arterial disease using asssessment of neovascularization by 99mTc-tetrofosmin (TF) perfusion scinitgraphy. Cell Transplant. 2004;13(4):429–437.
63.
AlveloJLPapdemetrisXMena-HurtadoC. Radiotracer imaging allows for noninvasive detection and quantification of abnormalities in angiosome foot perfusion in diabetic patients with critical limb ischemia and nonhealing wounds. Circ Cardiovasc Imaging. 2018;11(5). doi:10.1161/CIRCIMAGING.117.006932
64.
ScreminOUFigoniSFNormanK. Preamputation evaluation of lower-limb skeltal muscle perfusion with H(2)(15)O positron emission tomography. Am J Phys Med Rehabil. 2010;89(6):473–486. doi:10.1097/PHM.0b013e3181d89b08
65.
LueEWagnerWRSchellenbergerU. Targeted in vivo labeling of receptors for vascular endothelial growth factor: approach to identification of ischemic tissue. Circulation. 2003:108(1):97–103. doi:10.1161/01.CIR.0000079100.38176.83
66.
WillmannJKChenKWangH. Monitoring of the biological response to murien hindlimb ischemia with 64Cu-labeled vascular endothelial growth factor-121 positron emission tomography. Circulation. 2008;117(7):915–922.
