Vol.1, No.1, 16-19 (201
doi:10.4236/scd.2011.11002
C opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/SCD/
1) Stem Cell Discovery
Repeated application of autologous bone
marrow-derived stem cell therapy in patients
with severe Buerger’s disease
Zoltan Boda1, K. Razso1, M. Szarvas1, Zs. Olah1, P. Ilonczai1, Z. Vereb2, E. Rajnavolgyi2
1Department of Internal Medicine, University of Debrecen, Debrecen, Hungary;
2Department of Immunology, University of Debrecen, Debrecen, Hungary
Received February 18 2011; revised March 21 2011; accepted March 28 2011.
ABSTRACT
Stem cell therapy (SCT) is a promising and
prospective approach in the treatment of pa-
tients with severe peripheral arterial disorders,
primarily with Buerger’s disease. However, very
little is known about the duration of the effect of
SCT, and to our best knowledge no data are
available on the efficacy and safety of repeated
SCT in patients with Buerger’s disease. Here we
report on two patients with severe Buerger’s
disease, who received repeated autologous
bone marrow-derived stem cell therapy. Our
results show that a second SCT, applied to a
previously treated leg 30 or 36 months after the
first treatment was efficient in both cases. After
twelve months, the clinical state of the repeat-
edly treated lower limb improved spectacularly
and non-healing ulcers healed more rapidly
than after the first SCT. No severe adverse
events were detected. Thus repeated SCT offers
a safe and efficient treatment option for relaps-
ing patients at the advanced stage of Buerger’s
disease.
Keywords: Buerger’s Disease; No n H ealing Ulcer;
Repeated Bone Marrow-Derived Stem Cell Therapy
1. INTRODUCTION
Recent publications have proved the efficacy and
safety of stem cell therapy (SCT) in patients with severe
Buerger’s disease [1-14]. However, very little informa-
tion is available on the duration of the beneficial effect
of SCT [12], and according to our best knowledge no
data exist on the efficacy and safety of repeated SCT
carried out in patients with relapsing or worsening clini-
cal states in severe Buerger’s disease. Here we report on
two cases, where the lower limb of patients with Buer-
ger’s disease, previously treated by autologous bone
marrow-derived stem cell therapy (ABMSCT) [9], have
been re-treated with freshly isolated autologous bone
marrow derived isolated CD34+ cells. Both patients re-
lapsed at 30 - 36 months after the first ABMSCT. As
they responded to the first treatment, we decided to re-
peat ABMSCT with freshly isolated bone marrow de-
rived CD34+ cells by using the same method as de-
scribed in our previous publ ication [9].
2. MATERIALS AND METHODS
As it is a repeated stem cell therapy we refer to our
previous publ ication [9].
3. RESULTS
3.1. Case Reports
Patient 1 was a 59-year-old man with Buerger’s dis-
ease since 1976. He had rest pain, 50 m walking distance
without pain, and 2 large (8 cm2) and deep non-healing
ulcers on both feet. He had sympathectomy on both sides
(1982, 1983). A mputation of the righ t toe II and left toe I
was carried out in 1991, and the amputation of the left
toe III was done in 1995. Disease stage was Ler-
ishe/Fontain-IV before ABMSCT. As his left lower limb
was in a worse condition, we treated it by ABMSCT in
August 2006. The clinical state of this limb is still ex-
cellent (rest pain disappeared, the ischaemic ulcer healed
and has not relapsed so far), whereas the clinical state of
the untreated right limb became worse (rest pain in-
Presented at the 54th Annual Meeting of German Society of Throm-
bosis Haemostasis (GTH), Nuremberg, Febru ar y 2010.
Fundings: The present study was supported by the EEA/Norway
Grants HU-0046/NA/2006-2/ÖP-9 entitled
D
evelopment of novel stem
cell-based therapies for the treatment of advanced peripheral arteria
l
disease and by the TAMOP 4.2.2-08/1-2008-0015 EU supported NFÜ
p
rogram entitled Establishing a stem cell and gene therapy. Research
Centre at the University of Debrecen..

Z. Boda et al. / Stem Cell Discovery 1 (2011) 16-19
Copyright © 2011 SciRes. Openl y accessible at http://www.scirp.org/journal/SCD/
1717
creased, the ischaemic ulcer got larger and deeper). In
April 2007 ABMSCT was carried out on his right foot
(Figure 1 (a)) and nine months later we observed sig-
nificant improvement of the treated right foot (Figure 1
(b)). In October 2009, 30 months after the second SCT
the condition of his right limb relapsed with a large and
deep ischaemic ulcer at the same place (Figure 1 (c)).
His good response to previous treatments prompted us to
repeat ABMSCT on his right foot. Twelve months after
the repeated treatment, a significant improvement was
observed both in the general angiological state of the
limb and in the size of the ischaemic ulcer (Figure 1
(d)).
Patient 2 was a 40-year-old man with Buerger’s dis-
ease since 1991. He had rest pain, < 50 m walking dis-
tance without pain, and a large and deep non-healing
ulcer (36 cm2) on his left foot. He had sympatectomy on
both sides (1994 and 1995). He underwent amputations
of his left toe I-III and right toe I-II (1994), and left fin-
ger III (1999). Disease stage was Lerishe/Fontain-IV
before ABMSCT. SCT was given in September 2006
(a) (b)
(c) (d)
Figure 1. Repeated ABMSCT in a patient (D. A. 59 ys) with
severe Buerger’s disease. (a) Before first ABMSCT, (b) 9
months after first ABMSCT, (c) Relapse, 30 months after
first ABMSCT, D: 6 months after second ABMSCT.
(Figure 2 (a)) and after l2 months the clinical state of
the treated limb improved significantly as the non-heal-
ing ulcer healed and rest pain disappeared (Figure 2 (b)).
In October 2009, 36 months after SCT a large and deep
ischaemic ulcer re-appeared just at the same place as
before (Figure 2 (c)). Taken his previous clinical re-
sponse to therapy, we repeated ABMSCT and six
months after the treatment we detected complete healing
of the ischaemic ulcer (Figure 2 (d)). Simultaneously
the symptoms in the limb improved significantly.
4. DISCUSSION
Amputation is the only option for relief of rest pain or
large and deep ischaemic ulcers in patients with severe
Buerger’s disease. No effective blood-flow enhancement
therapies are available for these patients. ABMSCT is a
promising and prospective approach in the treatment of
severe peripheral arterial disorders, in particular in
Buerger’s disease. All of the published clinical trials
have reported on the affectivity and safety of ABMSCT
(a) (b)
(c) (d)
Figure 2. Repeated ABMSCT in a patient (F.T. 40 ys) with
severe Buerger’s disease. (a) before first ABMSCT, (b) after
12 months of first ABMSCT, (c) relapse, 36 months after
first ABMSCT, (d) 6 months after second ABMSCT.

Z. Boda et al. / Stem Cell Discovery 1 (2011) 16-19
Copyright © 2011 SciRes. Openl y accessible at http://www.scirp.org/journal/SCD/
18
in Buerger’s disease even thou gh the variatio n of the cell
populations and protocols used for the therapy [1-16].
It is well established that the bone marrow contains
multiple stem- and progenitor cells with the potential to
support vessel regeneration. As we proposed previously
[9], when these cells interact with tissue- and immune
cells in the inflammed milieu of the obstructed vessel,
they very likely acquire novel activities and trigger a
cascade of local events that support vasculogenesis and
wound healing. These complex mechanisms may in-
volve controlled production of soluble factors, regulation
of endothelial cell functions, formation of new vessels,
tissue regeneration, and inhibition of inflammation
[17,18]. These events altogether may support increased
blood flow, healing of ischaemic ulcers and ultimately
protect the leg from amputation.
Recently, Fadini et al. collected clinical data of 700
patients with peripheral arterial disorders treated by SCT
[15]. In patients with thromboangiitis obliterans (TAO)
showed larger benefits from SCT than patients with
atherosclerosis obliterans (ASO). The survival rate and
amputation-free state were markedly better in patients
with TAO than those in patients with ASO (100% vs.
80% and 91% vs. 60%). This metaanalysis indicates that
intramuscular introduction of autologous stem cells is a
feasible, safe and effective therapeutic strategy for pa-
tients with severe peripheral arterial disorders (PAD)
[15]. Currently 22 phase I-III clinical trials, using
ABMSCT in advanced ASO and TAO are going on. The
results of these trials will provide with important infor-
mation for the fina l consideration of stem cell therapy in
these diseases [15].
Very little information is available on the long term
effects of SCT that requires the clinical follow up of the
patients for years [12]. Furthermore, there are no clinical
data on the effects of repeated SCT neither in TAO nor
in ASO. Here we report on two patients with severe
Buerger’s disease who received repeated ABMSCT. In
both cases, the relapse occurred 30 - 36 months after the
first SCT. After six months of the repeated treatment
however, the clinical state of the treated limbs improved
considerably, the non-healing ulcers healed more rapidly
than during the first SCT without any severe adverse
events. Based on these observations we conclude that
repeated ABMSCT is safe and effective even in settings
of repeated treatments.
Stem cell therapy carried out on the left lower limb of
our first patient demonstrates an excellent clinical re-
sponse to the therapy with duration of almost 4 years,
despite its worse condition as compared to the right leg.
Although SCT was performed with the same technique
on both legs, the right limb relapsed 30 month s after the
treatment. We do not have a definite explanation for the
clinically different local responses of this patient to the
therapies performed at different time points, but it may
depend on the actual composition of the functionally
relevant stem- and progenitor cells. The quality control
of the autologous bone marrow-derived stem- and pro-
genitor cell suspensions performed as detailed in our
previous publication [9] revealed that no major differ-
ences in the ratios of CD34+ and CD34+CD133+ sub-
populations of the cell fractions used for the therapy
could be detect ed.
Remarkably, the large and deep ischemic ulcers ap-
peared in both cases at the same place as for the first
time. This observation points to a transient and incom-
plete regeneration process of vessels. Nevertheless, our
present results clearly show that relapsed cases of Buer-
ger’s disease can be treated by repeated ABMSCT with
high efficacy without adverse events.
5. CONCLUSION
Stem cell therapy is a promising and prospective
novel approach in the treatment of patients with severe
Buerger’s disease. In two cases the lower limb of pa-
tients with Buerger’s disease previously treated by
ABMSCT have been re-treated with freshly isolated
autologous bone-marrow derived CD34+ cells. Both pa-
tients relapsed at 30 - 36 months after the first ABMSCT.
Our present results clearly show that relapsed cases of
advanced Buerger’s disease can be treated by repeated
ABMSCT with high efficacy without adverse events.
6. ACKNOWLEDGEMENTS
This work was supported by the EEA/Norway Grants HU-0046/
NA/2006-2/ÖP-9 entitled Development of novel stem cell-based thera-
pies for the treatment of advanced peripheral arterial disease and by
the TAMOP 4.2.2-08/1-2008-0015 EU supported NFÜ program enti-
tled Establishing a stem cell and gene therapy. Research Centre at the
University of Debrecen.
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