Critical Lower Limb Ischemia, Type-2 Diabetes Mellitus
Conditions
Keywords
ischemia, diabetes mellitus, bone marrow aspirate concentrate (BMAC)
Brief summary
The aim of the presented clinical trial is to evaluate a hypothesis, that BMAC prepared from bone marrow aspirate and injected intramuscularly into ischemic areas of the lower extremity in patients with diabetes mellitus type II., intraarterially into the defect of the limb or with an intravenous application only, has a greater potential to improve the perfusion in the ischemic limbs than standard treatment of NO-CLI. Another aim of the study is to find out differences among three different therapeutic types of BMAC application, to define their effectiveness and safety and to compare the impact of different means of application to the speed of healing of the limb defects and the improvement of perfusion parameters.
Detailed description
Secondary hypothesis assumes, that the intravenous application of BMAC in patients with T2DM older than 30 years of age, with a dose of insulin exceeding 0.7 U/kg/day or 50U/day will result in decreasing the insulin dose in the course of 6-month follow-up and in an improvement of the glycHBA1c levels, improvement of the liver and kidney function, decrease of the cholesterol levels and improvement of the immune response parameters, i.e. parameters of lymphocytar blastic transformation, more than in case of patients with intramuscular or intraarterial application of BMAC.
Interventions
BIOLOGICALGroup A: Intramuscular
Intramuscular BMAC application The study subjects in the Group A will receive a treatment of 35ml BMAC administered intramuscularly into the affected limb, in individual punctures of 1 ml. The punctures will be applied into the crural muscle around the defect, the procedure takes approx. 60 minutes.
BIOLOGICALGroup B: Intraarterial
Intraarterial BMAC application The study subjects in the Group B will receive a treatment of 35ml BMAC administered intraarterially into the affected limb.
BIOLOGICALGroup C: Intravenous
Group C: Intravenous The study subjects in the Group C will receive a treatment of 35ml BMAC administered intravenously into the affected limb.
PROCEDUREGroup D: Surgical endovascular treatment with maximum medicamentous treatment
Group D: Control Group Control Group - no experimental intervention, standard endovascular treatment or bypass surgery or maximum medicamentous treatment
Sponsors
Ministry of Health, Czech Republic
Regional Council of the Moravian-Silesian region, KU MSK
University Hospital Ostrava
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* type 2 diabetes mellitus * diagnosis of critical limb ischemia * non-healing defect on the study limb * ABI value \< 50 mmHg or ABI\< 0.4 * TBI value \< 40 mmHg or TBI \< 0.4 * TcPO2 \< 20 mmHg in supine position * no other suitable surgical or re-vascularization procedure * age \> 18 years * signed Informed Consent
Exclusion criteria
* non-signing of the Informed Consent * anticipated life expectancy \< 6 months * history of bone-marrow disease * renal failure or dialysis dependency * known malignant disease * health risks excluding the possibility of general anaesthesia or sedation * life-threatening ischaemic heart disease * vast necrosis of the index limb * active infectious disease, or ATB treatment * treatment with immunosupressives * pregnancy, breastfeeding
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Amputation-free survival | 18 months | The data for Primary outcome will be collected throughout the first 18 months of the study. The assessed parameters will include amputation-free survival in order to verify the safety and efficacy of the treatment. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Clinical outcome classification | 4 years | The efficacy of BMAC application will be evaluated throughout the whole course of the clinical trial, with final assessment at the end of the trial. \- Improvement of the Rutherford scale of CLI |
| Tissue perfusion parameters | 4 years | The efficacy of BMAC application will be evaluated throughout the whole course of the clinical trial, with final assessment at the end of the trial. * Increase of the monitored parameters of the tissue perfusion measured with LDP-Periflux 5000 (Perimed), i.e. increase of the ABI - ankle-brachial index, TP - toe pressure, TBI- Toe Brachial index and TcpO2- transcutaneous oxygen pressure. * Decrease of the SPP perfusion parameter - skin perfusion pressure reflecting an inflammatory activity of the affected limb. |
| Functional angiogenesis imaging outcome | 4 years | The efficacy of BMAC application will be evaluated throughout the whole course of the clinical trial, with final assessment at the end of the trial. \- Increase of the number and quality of newly created vessels measured according to digital subtraction angiography (DSA) or MR-angiography (in allergic patients) |
| Quality of life outcome | 4 years | The efficacy of BMAC application will be evaluated throughout the whole course of the clinical trial, with final assessment at the end of the trial. * Measurable decrease of pain measured on the scale and QOL questionnaire (RAND-36). * Healing of the defect or gangrene (size and state of the wound) |
Other
| Measure | Time frame | Description |
|---|---|---|
| Blood glucose and pancreatic function response | 24 months | The following parameters will be monitored in the study subjects: * glycHBA1c levels * C-peptide |
| Metabolic response | 24 months | The following laboratory parameters throughout the clinical trial: * liver and kidney function * lipid spectra |
| Changes in lymphocyte subsets and levels of inflammatory and antiinflammatory cytokines in each of the groups. | 24 months | The immune response of study subjects will be monitored following the transplantation of stem cells, together with the periphery lymphocyte function (T-cells, B-cells, NK-cells). Immune response parameters, (i.e. parameters of lymphocytar blastic transformation) |
Countries
Czechia
Outcome results
None listed