Elsevier

The Lancet

Volume 348, Issue 9024, 10 August 1996, Pages 370-374
The Lancet

Early Report
Clinical evidence of angiogenesis after arterial gene transfer of phVEGF165 in patient with ischaemic limb

https://doi.org/10.1016/S0140-6736(96)03361-2Get rights and content

Summary

Background

Preclinical findings suggest that intra-arterial gene transfer of a plasmid which encodes for vascular endothelial growth factor (VEGF) can improve blood supply to the ischaemic limb. We have used the method in a patient.

Methods

Our patient was the eighth in a dose-ranging series. She was aged 71 with an ischaemic right leg. We administered 2000 μg human plasmid phVEGF165 that was applied to the hydrogel polymer coating of an angioplasty balloon. By inflating the balloon, plasmid DNA was transferred to the distal popliteal artery.

Findings

Digital subtraction angiography 4 weeks after gene therapy showed an increase in collateral vessels at the knee, mid-tibial, and ankle levels, which persisted at a 12-week view. Intra-arterial doppler-flow studies showed increased resting and maximum flows (by 82% and 72%, respectively). Three spider angiomas developed on the right foot/ankle about a week after gene transfer; one lesion was excised and revealed proliferative endothelium, the other two regressed. The patient developed oedema in her right leg, which was treated successfully.

Interpretation

Administration of endothelial cell mitogens promotes angiogenesis in patients with limb ischaemia.

Introduction

Among the growth factors that promote angiogenesis, vascular endothelial growth factor (VEGF),2 also known as vascular permeability factor,3 and vasculotropin,4 is specifically mitogenic for endothelial cells. The first exon of the VEGF gene includes a secretory signal sequence that permits the protein to be secreted naturally from intact cells.5 We have shown6, 7 that arterial gene transfer of naked DNA encoding for secreted protein yielded physiological levels of protein despite low transfection efficiency. Site-specific gene transfer of plasmid DNA encoding the 165-aminoacid isoform of human VEGF (phVEGF 165) applied to the hydrogel polymer coating of an angioplasty balloon,8 and delivered percutaneously to the iliac artery of rabbits in which the femoral artery had been excised to cause unilateral hindlimb ischaemia led to development of collateral vessels and increased capillary density, improved calf blood-pressure ratio (ischaemic/normal limb) and increased resting and maximum vasodilator-induced blood flow.9, 10 We now use this strategy in the ischaemic limb of a patient.

Section snippets

Patient

A 70-year-old non-diabetic woman was referred for gangrene of the right great toe. About a year earlier, the patient had cramping right-foot pain; several corns were removed, she was given intramuscular cortisone, prescribed ibuprofen, and fitted with shoe inserts. Symptoms worsened and the patient received oxycodone, hydrocodone, and a fentanyl patch. The great toe lesion progressed to gangrene, and the second and third toes became compromised. She had no palpable pedal pulses of the right

Results

Intravascular ultrasound immediately before gene transfer showed that the intended site, the distal popliteal artery, was free of atherosclerotic plaque that might compromise transfection efficiency.12 The arterial wall had a clearly recognisible three-layer appearance with no intimal thickening.13 Repeat ultrasound at 4 weeks and 12 weeks after gene transfer disclosed no neointimal thickening resulting from inflation of the hydrogel-coated angioplasty-balloon-catheter (figure 1).

Digital

Discussion

Beginning with Nabel et al,15 several laboratories showed the feasibility of arterial gene transfer in animal models. In December, 1994, we began a dose-escalating clinical trial.11 Doses of 100 and 500 μg of phVEGF165 administered to one patient each were inactive. 1000 μg improved lower extremity blood-flow in three of five patients, revealed by intravascular doppler analysis and magnetic resonance imaging. Contrast angiography, however, disclosed no new collateral vessels. DNA-labelling

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