US20060246044A1 - Methods for improving cell therapy and tissue regeneration in patients with cardiovascular and neurological diseases by means of shockwaves - Google Patents

Methods for improving cell therapy and tissue regeneration in patients with cardiovascular and neurological diseases by means of shockwaves Download PDF

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US20060246044A1
US20060246044A1 US11/304,865 US30486505A US2006246044A1 US 20060246044 A1 US20060246044 A1 US 20060246044A1 US 30486505 A US30486505 A US 30486505A US 2006246044 A1 US2006246044 A1 US 2006246044A1
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patient
tissue
cells
progenitor cells
shock waves
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Andreas Lutz
Harald Eizenhofer
Andreas Zeiher
Stefanie Dimmeler
Christopher Heeschen
Alexandra Aicher
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Dornier Medtech Systems GmbH
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Dornier Medtech Systems GmbH
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Publication of US20060246044A1 publication Critical patent/US20060246044A1/en
Priority to US12/214,660 priority patent/US9060915B2/en
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61H—PHYSICAL THERAPY APPARATUS, e.g. DEVICES FOR LOCATING OR STIMULATING REFLEX POINTS IN THE BODY; ARTIFICIAL RESPIRATION; MASSAGE; BATHING DEVICES FOR SPECIAL THERAPEUTIC OR HYGIENIC PURPOSES OR SPECIFIC PARTS OF THE BODY
    • A61H23/00—Percussion or vibration massage, e.g. using supersonic vibration; Suction-vibration massage; Massage with moving diaphragms
    • A61H23/008—Percussion or vibration massage, e.g. using supersonic vibration; Suction-vibration massage; Massage with moving diaphragms using shock waves
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/22—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for
    • A61B17/22004—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for using mechanical vibrations, e.g. ultrasonic shock waves
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K35/00—Medicinal preparations containing materials or reaction products thereof with undetermined constitution
    • A61K35/12—Materials from mammals; Compositions comprising non-specified tissues or cells; Compositions comprising non-embryonic stem cells; Genetically modified cells
    • A61K35/44—Vessels; Vascular smooth muscle cells; Endothelial cells; Endothelial progenitor cells
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/18—Growth factors; Growth regulators
    • A61K38/1858—Platelet-derived growth factor [PDGF]
    • A61K38/1866—Vascular endothelial growth factor [VEGF]
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/19—Cytokines; Lymphokines; Interferons
    • A61K38/195—Chemokines, e.g. RANTES
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P21/00—Drugs for disorders of the muscular or neuromuscular system
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/04—Centrally acting analgesics, e.g. opioids
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P9/00—Drugs for disorders of the cardiovascular system
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P9/00—Drugs for disorders of the cardiovascular system
    • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
    • A61B2017/00238—Type of minimally invasive operation
    • A61B2017/00243—Type of minimally invasive operation cardiac
    • A61B2017/00247—Making holes in the wall of the heart, e.g. laser Myocardial revascularization
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
    • A61B2018/00315—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body for treatment of particular body parts
    • A61B2018/00345—Vascular system
    • A61B2018/00351—Heart
    • A61B2018/00392—Transmyocardial revascularisation

Definitions

  • the present invention relates to methods for improving cell therapy in a patient. More specifically, the present invention relates to methods for improving cell therapy in patient who is suffering from a cardiovascular or a neurological disease by using shock waves as a therapeutic tool for targeting the recruitment of stem cells and/or progenitor cells to a tissue of the patient.
  • Stem and progenitor cells derived from the bone marrow may play a role in ongoing endothelial repair (Kalka et al., 2000). Impaired mobilization or depletion of these cells may contribute to endothelial dysfunction and cardiovascular disease progression. Indeed, in healthy men, levels of circulating progenitor cells may be a surrogate biologic marker for vascular function and cumulative cardiovascular risk. Recent advances in basic science have also established a fundamental role for endothelial stem and progenitor cells in postnatal neovascularization and cardiac regeneration. Improvement of neovascularization after critical ischemia is an important therapeutic option after myocardial infarction or limb ischemia.
  • angiogenesis neovascularization of ischemic tissue in the adult was believed to be restricted to migration and proliferation of mature endothelial cells, a process termed “angiogenesis”.
  • increasing evidence suggests that circulating stem and progenitor cells home to sites of ischemia and contribute to the formation of new blood vessels.
  • this process is referred to as “vasculogenesis”.
  • the importance of circulating stem and progenitor cells is demonstrated by the fact that genetic inhibition of their recruitment inhibits tumor angiogenesis.
  • VEGF vascular endothelial growth factor
  • SDF-1 stromal cell-derived factor
  • the present inventors have recently shown that infusion of bone marrow mononuclear cells derived from patients with ischemic heart disease is significantly less effective in improving perfusion of ischemic tissue in a hind limb ischemia animal model. Moreover, bone marrow cells of patients with ischemic heart disease reveal a reduced colony forming activity and an impairment of migratory response towards VEGF and SDF-1, which are potent chemoattractive and mobilizing agents (Heeschen C et al., Circulation 2004; 109(13): 1615-22.) Moreover, the present inventors were also able to demonstrate that in experimental models of tissue ischemia, recruitment of systemically infused stem/progenitor cells is significantly lower as compared to the recruitment of stem/progenitor cells derived from healthy donors.
  • Extracorporeal shock waves are generated by high voltage spark discharge under water. This causes an explosive evaporation of water, producing high energy acoustic waves. By focusing the acoustic waves with a semi-ellipsoid reflector, the waves can be transmitted to a specific tissue site (Ogden et al., 2001). ESW have been found beneficial in certain orthopedic conditions. The interactions of ESW with the targeted tissue are manifold: mechanical forces at tissue interfaces related to different acoustic impedances, as well as micro-jets of collapsing cavitation bubbles are the primary effects. However, the cellular and biochemical mechanisms, by which these physical effects may enhance healing of fractures, remain to be determined. It has been scintigraphically and sonographically implicated that local blood flow and metabolism of bone and Achilles tendon are positively affected by ESW treatment (Maier et al., 2002).
  • ESW therapy has shown to be effective in the treatment of orthopedic conditions including non-union of long bone fracture, calcifying tendonitis of the shoulder, lateral epicondylitis of the elbow, proximal plantar fasciitis, and Achilles tendonitis (Kruger et al., 2002).
  • the success of shock wave therapy ranges from 80% for non-unions of long bone fractures to 15-90% for tendinopathies of the shoulder, elbow and heel.
  • the short-term results of shock wave therapy for avascular necrosis of the femoral head appear encouraging.
  • Shock wave therapy also showed a positive effect in promoting bone healing in animal experiments. Despite the success in clinical application, the exact mechanism of shock wave therapy remains unknown.
  • shock wave therapy enhanced neovascularization at the tendon-bone junction (Wang et al., 2002). It was hypothesized that shock wave therapy may have the potential to induce the ingrowth of new blood vessels and improvement of blood supply that lead to tissue regeneration. Indeed, a recent study in rabbits showed that shock wave therapy induces the ingrowth of neovessels and tissue proliferation associated with the early release of angiogenesis-related factors including endothelial nitric oxide synthase (eNOS) and VEGF at the tendon-bone junction in rabbits (Wang et al., 2003).
  • eNOS endothelial nitric oxide synthase
  • VEGF vascular endothelial nitric oxide synthase
  • the mechanism of shock wave therapy may involve the early release of angiogenic growth factors and subsequent induction of cell proliferation and formation of neovessels at the tendon-bone junction.
  • the occurrence of neovascularization may lead to the improvement of blood supply and play a role in tissue regeneration at the tendon-bone junction.
  • ESW therapy ameliorates ischemia-induced myocardial dysfunction in pigs in vivo (Nishida et al., 2004).
  • post infarction heart failure remains a major cause of morbidity and mortality in patients with coronary heart disease.
  • ventricular remodeling processes characterized by progressive expansion of the infarct area and dilation of the left ventricular cavity result in the development of heart failure in a sizeable fraction of patients surviving an acute myocardial infarction.
  • the major goal to reverse remodeling would be the stimulation of neovascularization as well as the enhancement of regeneration of cardiac myocytes within the infarct area.
  • Peripheral neuropathy describes damage to the peripheral nerves. It may be caused by diseases of the nerves or as the result of systemic illnesses. Many neuropathies have well-defined causes such as diabetes, uremia, AIDS, or nutritional deficiencies. In fact, diabetes is one of the most common causes of peripheral neuropathy. Other causes include mechanical pressure such as compression or entrapment, direct trauma, fracture or dislocated bones; pressure involving the superficial nerves (ulna, radial, or peroneal); and vascular or collagen disorders such as atherosclerosis, systemic lupus erythematosus, scleroderma, and rheumatoid arthritis.
  • peripheral neuropathy Although the causes of peripheral neuropathy are diverse, they produce common symptoms including weakness, numbness, paresthesia (abnormal sensations such as burning, tickling, pricking or tingling) and pain in the arms, hands, legs and/or feet. A large number of cases are of unknown cause.
  • Therapy for peripheral neuropathy differs depending on the cause.
  • therapy for peripheral neuropathy caused by diabetes involves control of the diabetes.
  • treatment may consist of splinting or surgical decompression of the ulnar or median nerves.
  • Peroneal and radial compression neuropathies may require avoidance of pressure.
  • Physical therapy and/or splints may be useful in preventing contractures (a condition in which shortened muscles around joints cause abnormal and sometimes painful positioning of the joints).
  • Ischemic peripheral neuropathy is a frequent, irreversible complication of lower extremity vascular insufficiency. It has been shown that ischemic peripheral neuropathy can be prevented and/or reversed by gene transfer of an endothelial cell mitogen (e.g. VEGF) designed to promote therapeutic angiogenesis (Schratzberger P, et al.). The major goal to reverse vascular insufficiency would thus be the stimulation of angiogenesis and the regeneration of the vascular tissue within the area affect by peripheral neuropathy.
  • an endothelial cell mitogen e.g. VEGF
  • the technical problem underlying the present invention in thus to enhance the cell therapy and regeneration of tissues affected by a cardiovascular or a neurological disease.
  • this problem is solved by the provision of a method for improving cell therapy in a patient suffering from a cardiovascular disease or a neurological disease comprising a treatment by means of shock waves of an tissue of the patient affected by the disease, which tissue is targeted for cell therapy.
  • the present invention provides, in part, a therapeutic tool improving the targeted recruitment of stem and progenitor cells in patients undergoing cell therapy.
  • the present invention relates to methods for improving cell therapy in a patient who is suffering from a cardiovascular or a neurological disease and is undergoing cell therapy by using shock waves as a therapeutic tool for targeting the recruitment of stem cells and/or progenitor cells to a tissue of the patient.
  • the present invention also relates to methods for improving tissue regeneration in a patient suffering from a cardiovascular or neurological disease by treating a tissue of the patient affected by the disease using shock waves.
  • methods for treating a cardiovascular or neurological disease in a patient comprising the treatment of a tissue of the patient affected by the disease by means of shock waves, and applying to the patient a therapeutically effective amount of stem cells and/or progenitor cells.
  • the present invention further also relates to the use of stem cells and/or progenitor cells for preparing a pharmaceutical composition for treating a patient suffering from a cardiovascular disease or a neurological disease, wherein the patient is subjected to a treatment with shock waves before, during, or after administration of the stem cells and/or progenitor cells.
  • the present inventors have recently shown that autologous stem and progenitor cells in patients with cardiovascular risk factors have a reduced ability to home and migrate to damaged tissue. Since the expression of chemoattractant factors in chronically injured tissue is markedly reduced as compared to acute injury, the overall recruitment of stem/progenitor cells in patients with cardiovascular risk factors is impaired.
  • the invention involves the treatment of tissue that is targeted for therapy with stem and progenitor cells by means of shock waves to increase the expression of chemoattractants (i.e. factors mediating the attraction of circulating stem and progenitor cells, e.g. SDF-1 ⁇ , VEGF, P1GF) and pro-angiogenic factors (i.e.
  • pro-survival factors i.e. factors stimulating pre-existing endothelial cells to form new vessels
  • pro-survival factors i.e. factors inhibiting apoptosis/programmed cell death, e.g. HGF, IGF, VEGF.
  • the increased expression of chemoattractant and pro-angiogenic factors will improve the recruitment of systemically infused stem and/or progenitor cells, and enhanced expression of pro-survival factors will improve the microenvironment for cells directly administered into the target tissue.
  • the homing of stem and progenitor cells will be enhanced. Thereby, shock wave treatment of the targeted tissue will enhance the therapeutic effect of cell therapy.
  • ESW extracorporeal shock waves
  • stem cells and/or progenitor cells By combining the application of extracorporeal shock waves (“ESW”) and the application of stem cells and/or progenitor cells, the regeneration of cardiovascular and neurological diseases may be improved.
  • the combination of ESW and the application of stem cells and/or progenitor cells may be used to treat cardiovascular and neurological diseases.
  • FIG. 1 is a block diagram depicting shock wave-induced vascular endothelial growth factor (“VEGF”) expression in rat hindlimb muscles detected by Western blot, according to an exemplary embodiment of the invention.
  • VEGF vascular endothelial growth factor
  • FIG. 2A is a representative image of shock wave-induced VEGF expression in rat hind limb muscles detected by VEGF staining on frozen sections, according to an exemplary embodiment of the invention.
  • FIG. 2B is a block diagram depicting shock wave-induced VEGF expression in rat hind limb muscles detected by VEGF staining on frozen sections, according to an exemplary embodiment of the invention.
  • FIG. 3A is a representative image of detection of intravenously injected endothelial progenitor cells (“EPCs”) after shock wave treatment, wherein 10- ⁇ m frozen sections were analyzed for EPCs (red fluorescence) and nuclei were stained with Tropro-3 (blue fluorescence), according to an exemplary embodiment of the invention.
  • EPCs endothelial progenitor cells
  • FIG. 3B is a block diagram depicting quantification of intravenously injected EPCs that were recruited to shock wave treated muscles, according to an exemplary embodiment of the invention.
  • FIG. 4A is a series of representative images of the ischemic (left) and non-ischemic (right) limb for animals that received either no treatment, EPC infusion only, shock wave pretreatment only, or both, according to an exemplary embodiment of the invention.
  • FIG. 4B is a block diagram depicting quantitative perfusion data generated by calculating the ratio of the perfusion of the ischemic to the non-ischemic limb, according to an exemplary embodiment of the invention.
  • the invention is related to a method for improving cell therapy in a patient suffering from a cardiovascular disease or a neurological disease comprising a treatment by means of shock waves of a tissue of the patient affected by the disease, which tissue is targeted for cell therapy.
  • the invention in another aspect, relates to a method for improving the tissue regeneration in a patient suffering from a cardiovascular disease or a neurological disease comprising the steps of treating a tissue of the patient affected by the disease by means of shock waves, and applying to the patient a therapeutically effective amount of stem cells and/or progenitor cells.
  • the invention is related to a method for treating a cardiovascular disease or a neurological disease in a patient comprising the steps of treating a tissue of the patient affected by the disease by means of shock waves, and applying to the patient a therapeutically effective amount of stem cells and/or progenitor cells.
  • the treatment of the patient by shock waves is carried out prior to the administration of the stem and/or progenitor cells.
  • a simultaneous application of both shock waves and stem/progenitor cells and a subsequent application of shock waves is also contemplated.
  • the invention relates to a use of stem and/or progenitor cells for preparing a pharmaceutical composition for treating a patient suffering from a cardiovascular disease or neurological disease, wherein the patient is subjected to a treatment with shock waves before, during, or after administration of the stem and/or progenitor cells.
  • cell therapy refers to the transplantation of cells to replace or repair damaged tissue and/or cells.
  • Cell therapy involves the use of blood transfusions and bone marrow transplants, as well as injections of cellular materials.
  • shock waves is used interchangeably with the term “acoustical pressure pulse”.
  • stem cell refers to an unspecialised cell that is capable of replicating or self-renewing itself and developing into specialized cells of a variety of cell types.
  • the product of a stem cell undergoing division is at least one additional cell that has the same capabilities as the original cell.
  • stem cell is intended to encompass embryonal and adult stem cells, totipotent and pluripotent cells, and autologous cells, as well as heterologous cells.
  • progenitor cell also known as a precursor cell
  • progenitor cell is intended to encompass cells which are yet undifferentiated but may already be committed to a specific cell type (e.g. endothelial progenitor cells are committed to differentiate into endothelial cells).
  • the patient's disease is a cardiovascular disease.
  • the cardiovascular disease has a non-ischemic etiology.
  • An example of a cardiovascular disease with a non-ischemic etiology which can be treated by the methods according to the invention is dilatative cardiomyopathy.
  • the cardiovascular disease may have an ischemic etiology.
  • Cardiovascular diseases with an ischemic etiology which may be improved by cell therapy include myocardial infarctions and ischemic cardiomyopathies. Chronic ischemic cardiomyopathy is particularly preferred.
  • the patient's disease is a neurological disease.
  • the neurological disease is peripheral neuropathy or neuropathic pain.
  • the affected tissue is located in the heart or in a skeletal muscle.
  • chemoattractant factor is used herein to refer to a factor activating the movement of individual cells, in response to a chemical concentration gradient.
  • the at least one chemoattractant factor is vascular endothelial growth factor, VEGF, or stromal cell derived factor 1, SDF-1.
  • the shock waves used in the methods and uses according to the invention preferably are extracorporeal shock waves which may, for instance, be applied extra-thoracal.
  • extracorporeal shock waves delivered e.g. trans-esophageal
  • endoscopic shock waves delivered e.g. intraluminal such as in the artery
  • the shock waves may be applied during open surgery (intra-operative).
  • shocks per area and/or a total number of 100, 250, 500, 1000, or 1500 shocks per treatment are applied.
  • shocks with an energy of 0.05, 0.09, 0.13; 0.22, 0.36, or 0.50 mJ/mm 2 are applied.
  • the shock waves may be applied once or several times prior to cell therapy; an application once or twice prior to cell therapy is preferred.
  • the shock waves are applied several hours before the start of the cell therapy; an application 24 h, 36 h, or 48 h prior to cell injection is particularly preferred.
  • the shock waves may be exclusively or additionally be applied during cell therapy and/or after the start of the cell therapy.
  • the stem and/or progenitor cells which are used in the methods and uses according to the invention are embryonic or umbilical cord-blood derived cells.
  • the stem and/or progenitor cells are adult cells.
  • Adult stem and/or progenitor cells can be derived from bone marrow, peripheral blood, and organs.
  • the cells can be derived from healthy donors or patients suffering from coronary heart disease.
  • the stem and/or progenitor cells are isolated and, optionally, cultivated ex vivo before being applied.
  • stem and/or progenitor cells may be used in the methods and uses according to the invention:
  • CD34-CD45 ⁇ bone marrow-derived mesenchymal stem cells (MSC)
  • stage-specific embryonic antigen SSEA-4+Oct4+ embryonic stem cells
  • CD34+CD45+ cord blood-derived stem cells CD34+CD45+ cord blood-derived stem cells.
  • the stem and/or progenitor cells used in the methods and uses according to the invention may be applied by way of systemic infusion, local arterial infusion, venous infusion, and/or by direct injection into the affected tissue.
  • the cells may further be encapsulated in microspheres (targeted drug delivery). Contrast agents used for ultrasound are examples for useful encapsulation agents.
  • the cells may then be released from the microspheres at the targeted tissue using ultrasound (acoustic energy).
  • a prerequisite for the success of cell therapy is the homing and, thus, engraftment of transplanted cells into the target area, especially if an intravascular route of administration is chosen.
  • the present inventors have now shown that the migratory capacity of adult progenitor cells towards their physiological chemo-attractant reflects their homing capacity into the ischemic/infarcted area.
  • enhancing the recruitment of stem/progenitor cells is a novel target for improving the clinical outcome after autologous cell therapy in aged individuals and patients with cardiovascular risk factors;
  • peripheral blood was freshly drawn and collected in heparin monovettes (10 ml).
  • Dulbecco's Phosphate Buffered Saline without calcium and magnesium (Cat. No. H-15-002) was used for suspension of the cells for injection.
  • PAA was purchased from Laboratories GmbH (Pasching, Austria).
  • Fetal Bovine Serum (Cat. No.
  • Mononuclear cells are separated from freshly collected peripheral blood or buffy coats from the blood donation center using Ficoll gradient centrifugation.
  • 15 ml Biocoll separation solution are provided per 50 ml tube.
  • the peripheral blood (PB) is diluted with PBS (PB 1:1 or buffy coats 1:4).
  • 25 ml of the diluted blood are overlayed on 15 ml of the Biocoll separation solution.
  • the tube is centrifugated at 800 ⁇ g for 20 min at room temperature without brake. This is an important step to separate the mononuclear cells (in the interphase) from erythrocytes and granulocytes (pellet) and platelets in the upper serum phase.
  • wells are coated with 10 ⁇ g/ml human fibronectin in PBS, and the wells are incubated for at least 30 min at room temperature.
  • the mononuclear cells are pipetted from the interphase carefully in a new 50 ml tube.
  • PBS is added to 50 ml to wash the cells.
  • the cells were centrifugated at 800 ⁇ g for 10 min at room temperature (with brake). The supernatant was removed and the cell pellet was resuspended in 50 ml PBS.
  • the cells were centrifugated at 800 ⁇ g for 10 min at room temperature (with brake), the supernatant was removed and the cell pellet was resuspended in 10 ml PBS.
  • the supernatant is removed and the cell pellet is resuspended in culture medium (endothelial basal medium supplemented with 20% FBS, epidermal growth factor (10 ⁇ g/mL), bovine brain extract (3 ⁇ g/mL), gentamicin (50 ⁇ g/mL), hydrocortisone (1 ⁇ g/mL), VEGF (100 ng/ml) to a cell concentration of 8 ⁇ 10 6 cells/ml medium.
  • Fibronectin is then removed from the dishes.
  • the cells are added to the fibronectin-coated wells at a density of approx.
  • EPCs adherent endothelial progenitor cells
  • EPCs were washed with PBS, trypsinized for 2 min, then the reaction was stopped with serum-containing RPMI medium. Detached EPCs were washed again with PBS, incubated with CM-Dil (Molecular Probes) diluted in PBS (1:100) for 5 min at 37° C., followed by incubation for 15 min on ice. After washing, 1 ⁇ 10 6 CM-Dil-labeled EPCs were injected into the jugular vein of nude rats pre-treated with shock wave therapy.
  • CM-Dil Molecular Probes
  • Shock waves were applied at graded doses of flux density (0.13-0.64 mJ/mm 2 ; 3 Hz; 500 impulses) to the upper right hind limb of nude rats. The energy was focused on the upper limb, while moving the focus distally for 2 mm after every 100 impulses.
  • shock wave treatment up-regulates pro-angiogeneic growth factors such as VEGF, which is chemoattractant for VEGF receptor 1 or 2 positive stem and progenitor cells that are injected after 24 h.
  • VEGF pro-angiogeneic growth factors
  • the right hind limb of nude rats was treated with a flux density of 0.13, 0.22, 0.43, and 0.64 mJ/mm 2 ( FIG. 1 ).
  • the left hind limb was used as a negative control (0 mJ/mm 2 ).
  • the shock wave-induced up-regulation of VEGF protein expression was analyzed in the treated versus the untreated hind limb by means of Western blotting.
  • rats were sacrificed and the adductor muscle of the right and left hind limbs were removed, frozen in liquid nitrogen, and minced in a mortar using 1 ml protein lysis buffer (20 mmol/L Tris (pH 7.4), 150 mmol/L NaCl, 1 mmol/L EDTA, 1 mmol/L EGTA, 1% Triton, 2.5 mmol/L sodium pyrophosphate, 1 mmol/L ⁇ -glycerophosphate, 1 mmol/L Na3VO4, 1 ⁇ g/mL leupeptin and 1 mmol/L phenylmethylsulfonyl fluoride) for 15 min on ice.
  • 1 ml protein lysis buffer (20 mmol/L Tris (pH 7.4), 150 mmol/L NaCl, 1 mmol/L EDTA, 1 mmol/L EGTA, 1% Triton, 2.5 mmol/L sodium pyrophosphate, 1 mmol/L ⁇
  • VEGF expression was detected as cytoplasmic and secreted VEGF staining (green fluorescence) with respect to nuclear staining (blue fluorescence). Since flux densities higher than 0.43 mJ/mm 2 led to high unspecific background levels of VEGF expression, only flux densities between 0.13 mJ/mm 2 and 0.43 mJ/mm 2 were used ( FIG. 2 b ).
  • VEGF + cells per high power (HP) view was determined for 0.13, 0.22, and 0.43 mJ/mm 2 .
  • EPCs were labeled with a red fluorescent cell tracker and infused intravenously 24 h after shock wave therapy of the right hind limb. Since the best results for VEGF staining in cyrosections had been obtained using energy of 0.43 mJ/mm 2 , the following experiments were performed using the same flux density.
  • CM-Dil + (red fluorescent) human EPCs (1 ⁇ 10 6 ) were intravenously injected. The animals were sacrificed after 72 h and the tissue was evaluated for red fluorescent EPCs incorporated into vessel structures. The number of red fluorescent cells in the shock wave-treated right versus the untreated left hind limb was analysed.
  • Hind limb ischemia model The in vivo neovascularization capacity of infused human EPC was investigated in a rat model of hind limb ischemia, by use of 5 wk old athymic nude rats (Charles River Laboratory) weighing 100-120 g. The proximal portion of the femoral artery including the superficial and the deep branch as well as the distal portion of the saphenous artery were occluded using an electrical coagulator. The overlying skin was closed using surgical staples. Three weeks after induction of hind limb ischemia, chronic ischemia was assessed by Laser Doppler imaging. Only rats with evidence for chronic ischemia were randomized for one of the four treatment groups: Shock wave Group pretreatment EPC infusion 1 ⁇ ⁇ 2 ⁇ + 3 + ⁇ 4 + + +
  • EPCs were infused 24 hours after shock wave pretreatment.
  • the ischemic (right)/non-ischemic (left) limb blood flow ratio was determined using a laser Doppler blood flow imager (Laser Doppler Perfusion Imager System, moorLDITM-Mark 2, Moor Instruments, Wilmington, Del.). Before initiating scanning, mice were placed on a heating pad at 37° C. to minimize variations in temperature. After twice recording laser Doppler color images, the average perfusions of the ischemic and non-ischemic limb were calculated. To minimize variables including ambient light and temperature, calculated perfusion is expressed as the ratio of ischemic to non-ischemic hind limb perfusion.

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