Increased Vascularity Detected by Digital Subtraction Angiography after VEGF Gene Transfer to Human Lower Limb Artery: A Randomized, Placebo-Controlled, Double-Blinded Phase II Study

Abstract

Vascular endothelial growth factor (VEGF) gene therapy may be useful for the treatment of lower-limb ischemia. The objectives of this study were to evaluate safety and angiographic and hemodynamic responses of local catheter-mediated VEGF gene therapy in ischemic lower-limb arteries after percutaneous transluminal angioplasty (PTA). For this study, we recruited patients with chronic lower-limb ischemia and atherosclerotic infrainguinal occlusion or stenosis suitable for PTA. In the study, 18 patients received 2x10(10) plaque-forming units (pfu) VEGF-adenovirus (VEGF-Ad), 17 patients received VEGF-plasmid/liposome (VEGF-P/L; 2000 microg of VEGF plasmid, 2000 microl of DOTMA:DOPE), and 19 control patients received Ringer's lactate at the angioplasty site. Digital subtraction angiography (DSA) was used to evaluate vascularity before, immediately after, and 3 months after the PTA. Clinical follow-up data, basic laboratory tests, and ankle-brachial index (ABI) were evaluated. Primary endpoint was DSA analysis of vascularity, and secondary endpoints were restenosis rate, Rutherford class, and ABI after 3 months follow-up. No major gene transfer-related side effects or differences in laboratory tests were detected between the study groups. However, anti-adenovirus antibodies increased in 61% of the patients treated with VEGF-Ad. For the primary endpoint, follow-up DSA revealed increased vascularity in the VEGF-treated groups distally to the gene transfer site (VEGF-Ad P=0.03, VEGFP/L P=0.02) and in the VEGF-Ad group in the region of the clinically most severe ischemia (P=0.01). As for the secondary endpoints, mean Rutherford class and ABI showed statistically significant improvements in the VEGF-Ad and VEGF-P/L groups, but similar improvements were also seen in the control patients. We conclude that catheter-mediated VEGF gene therapy is safe and well tolerated. Angiography demonstrated that VEGF gene transfer increased vascularity after PTA in both VEGF-Ad- and VEGF-P/L-treated groups.

A Five-Year Study of the Efficacy of Purified CD34+ Cell Therapy for Angiitis-Induced No-Option Critical Limb Ischemia

“…Many studies using different methods, such as vascular endothelial growth factor (VEGF)‐related gene transfer 6, 7, bone‐marrow mononuclear cell (BMMNC) 8, 9, 10, 11, 12, PBMNC 13, 14, 15, 16, 17, 18, or CD34+ cell 2, 3, 4 transplantation, have been completed and have proven their safety and efficacy. The long‐term outcome after CD34+ cell therapy in CLI patients was already reported by Kinoshita et al in 2012 19.…”

Eight-year safety follow-up of coronary artery disease patients after local intracoronary VEGF gene transfer

“…4,9 Adenoviruses containing a CMV-hVEGF 165 expression cassette were produced under good clinical practice GMP in 293 cells, as described. 4 They were analyzed for the absence of replication-competent viruses by means of a cytopathic effect assay on A549 cells, and viral preparations were examined to be free of any microbiological or endotoxin contamination (o20 EU/dose, Whittaker). 9,12 DOTMA:DOPE (1:1) liposomes (Valentis Inc., Burlingame, CA, USA).…”

“…Plasmids used for this study were manufactured under GMP, and were analyzed to be Long-term safety of VEGF gene therapy M Hedman et al free of any microbiological or endotoxin contamination (o200 EU per dose) as described. 2,4 Percutaneous coronary intervention was carried out according to standard clinical practice, using the femoral approach. Stenting was used in 92 (90%) patients.…”

“…It is also a cytoprotective and anti-apoptotic factor leading to the inhibition of neointimal growth during vascular damage, and inducing angiogenesis especially in ischaemic tissues. [1][2][3][4][5][6][7] Therapeutic angiogenesis and inhibition of restenosis were the first targets of VEGF gene therapy. 2,5,7,8 The VEGF family consists of several members: VEGF (also called VEGF-A), VEGF-B, VEGF-C, VEGF-D, VEGF-E, VEGF-F and placental growth factor.…”

Post-intervention vessel remodeling

“…1 In a randomized, controlled phase II study of catheter-mediated VEGF-A gene transfer with plasmid/liposome or adenovirus to infrainguinal arteries after PTA, increased vessel formation was seen in the VEGF treatment groups in the follow-up angiography 3 months after the gene transfer, but no effect was found on restenosis. 44 The first anti-sense-based clinical study for in-stent restenosis was recently published by Kutryk et al 45 They used antisense oligonucleotides against cmyc to inhibit cell proliferation in stented lesions. Although the pre-clinical results in preventing intimal hyperplasia with this cell cycle regulator were very promising, the study did not show any therapeutic effect measured by intravascular ultrasound and angiography.…”