骨髓动员刺激后自体骨髓源单个核细胞移植治疗下肢缺血的初步临床研究

目的观察骨髓动员刺激后自体骨髓单个核细胞移植治疗下肢缺血的初步疗效。方法2005年5月～2005年12月收治下肢缺血35例43侧患肢，男23例，女12例。年龄34～90岁，平均71．3岁。病因：糖尿病下肢缺血30例38侧患肢，单纯动脉硬化闭塞症2例2侧患肢，血栓闭塞性脉管炎3例3侧患肢。其中间歇性跛行期5例5侧患肢；静息痛期15例19侧患肢；组织缺损期15例19侧患肢，其中组织溃疡期9例12侧患肢；组织坏疽期6例7侧患肢。在抽取骨髓前使用粒细胞集落刺激因子刺激骨髓2～3d，每天300μg；抽取骨髓血130-200ml，经分离纯化后再行移植。采用下肢肌肉局部注射13例19侧患肢，下肢动脉腔内注射16例16侧患肢，下肢肌肉局部注射与动脉腔内同时注射6例8侧患肢进行移植。结果术后2个月肢体疼痛改善率为94．7％，冷感改善率为97．1％，肢体麻木改善率为93．3％。5例5侧患肢间歇性跛行距离均有不同程度增加。44．2％患者的踝肱比值（ankle／brachial index ABI）有不同程度增加。39侧患肢行经皮氧分压（transeutaneous oxygen pressure，TeP02）测定，92．3％有不同程度增高。患肢溃疡：在9例11侧患肢中，愈合1侧，明显缩小或缩小3侧，无变化7侧，其中3侧患肢被截肢。术后行血管造影评估25例34侧患肢，91．2％患肢的侧支循环有不同程度增加。并发症：骨髓动员刺激出现发热和轻微乏力各1例，均自行缓解；单个核细胞移植后1周出现轻度心肌梗死1例，药物治疗1周后恢复出院，1个月后因患肢疼痛加重行膝下截肢。32例40侧患肢获随访3412个月，症状消失13侧，明显改善15侧，改善8侧，复发2侧，无效2侧。客观评价标准与术前比较ABI增加25侧；TcPOz测定增加36侧；21侧患肢的血管造影显示90．5％患肢有新生侧支形成；10侧患肢足部溃疡7侧愈合，3侧明显缩小；3侧患肢截除坏疽足趾者于术后2～3个月愈合出院。结论经骨髓动员刺激后的骨髓单个核细胞移植下肢缺血，具有抽取骨髓血少、细胞量多、近期效果好且安全性高的优点，是除自体骨髓单个核细胞移植和外周血干细胞移植外的又一种治疗下肢缺血的新方法。远期效果尚需进一步随访。

A CLINICAL STUDY ON IMPLANTATION OF AUTOLOGOUS BONE MARROW MONONUCLEAR CELLS AFTER BONE MARROW STIMULATION FOR TREATMENT OF LOWER LIMB ISCHEMIA

OBJECTIVE: To observe the clinical efficiency of the implantation of the autologous bone marrow mononuclear cells for treatment of lower limb ischemia after the bone marrow stimulation. METHODS: From May to December 2005, 43 ischemic limbs in 35 patients (23 males, 12 females; aged 34-90 years,averaged 71.3 year) were treated. Of the 35 patients, 30 had diabetic lower limb ischemia with 38 lower ischemic limbs, 2 had atherosclerosis obliterans with 2 ischemic lower limbs, and 3 had thromboangiitis obliterans with 3 ischemic lower limbs. Five patients with 5 ischemic limbs were in stage I lower limb ischemia (intermittent claudication), 15 patients with ischemic 19 limbs were in stage II (rest pain), 9 patients with 12 ischemic limbs were in stage IIIa (ulceration), and 6 patients with 7 ischemic lower limbs in stage IIIb (gangrene); 88.4% of all the ischemic lower limbs (38/43)had a pain, 79.1% (34/ 43) had coldness, and 69.8% (30/43) had limb numbness. The bone marrow of each patient was stimulated by an injection of the recombinant human granulocyte-macrophage colony-stimulatory factor (GSF), 300 microg/d for 2-3 days. The bone marrow 130-200 ml was drawn from the iliac spine and the mononuclear cells were obtained. Each patient received implantation of the autologous bone marrow mononuclear cells by an intramuscular injection, an arterial intraluminal injection or a combined injection of the two routes. RESULTS: The pain relief was found in 94.7% of the ischemic lower limbs, and pain improvement in 97.1% . Relived numbness was found in 93.3%. The distance of the claudication was increased by all the ischemic limbs. An increase in the ankle/ brachial index (ABI) was found in 47.9%. The transcutaneous oxygen pressure (TcPO2) increased in 92.3%. The ulcer heal rate was 9.1% (1/11). Markedly-reduced ulcer wound was found in 27.3% (3/11). The amputation rate was 6.3% (3/48). Arterial angiography revealed that there was a new collateral vessel formation in 91.2%. Complications were as follows: fever and mild fatigue developed respectively in 1 patient after the bone marrow stimulation, but relieved by themselves. Acute but mild myocardial infarction was found in 1 patient with a slight precordial pain and elevation of myocardial enzymes 1 week after transplantation of the bone marrow mononuclear cells, but recovered after medical treatment. The follow-up averaged 5 months. According to the subjective criteria, the overall efficacy was 90%. ABI increased in 62.5% of the patients after operation and the value of TcPO2 was higher in 90% of the patients after this kind of therapy. Arterial angiography revealed a new collateral vessel formation in 90.5% of the 21 ischemic limbs. The foot ulcer healed in 7 and obviously improved in 3. Three of the foot ulcer patients were discharged 2-3 months after the amputation was performed on the diseased toes. CONCLUSION: Implantation of the autologous bone marrow mononuclear cells after the bone marrow stimulation of treatment of the lower limb ischemia has advantages of less marrow aspiration, more mononuclear cell content, satisfactory short-term effect, and relatively high safety. It is a new method of treating the lower limb ischemia besides the autologous bone marrow and peripheral blood mononuclear cell implantation. The long-term effect of this method needs a further study.