Клеточные технологии в лечении терминальной стадии
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40 Îáçîðû Êëåòî÷íûå òåõíîëîãèè â ëå÷åíèè òåðìèíàëüíîé ñòàäèè õðîíè÷åñêîé èøåìèè íèæíèõ êîíå÷íîñòåé À.Á. Ñìîëÿíèíîâ1, Å.Â. Ïûõòèí1, Ä.Â. Áóëãèí1, Ì. Òîìîíàãà 2 Öåíòð êëåòî÷íîé è ãåííîé òåðàïèè, Ïîêðîâñêèé áàíê ñòâîëîâûõ êëåòîê, Ñàíêò-Ïåòåðáóðã, Ðîññèÿ 2 Äåïàðòàìåíò ìîëåêóëÿðíîé ìåäèöèíû è ãåìàòîëîãèè, Ìåäèöèíñêèé ôàêóëüòåò Óíèâåðñèòåòà Íàãàñàêè, ßïîíèÿ 1 Cell technologies in the treatmemt of critical lower limbs ischemia A.B. Smolyaninov1, E.V. Pykhtin1, D.V. Bulgin1, M. Tomonaga 2 1 Center of Cell and Gene Therapy, Stem cell Bank «POKROVSKI», St.-Petersburg, Russia 2 Department of Molecular Medicine and Hematology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan  ñòàòüå ïðåäñòàâëåí îáçîð âàðèàíòîâ ïðèìåíåíèÿ êëåòî÷íûõ òåõíîëîãèé â ëå÷åíèè òåðìèíàëüíîé ñòàäèè õðîíè÷åñêîé èøåìèè íèæíèõ êîíå÷íîñòåé. Îñíîâíûì ìåòîäîì ëå÷åíèÿ ñîñóäèñòûõ çàáîëåâàíèé íèæíèõ êîíå÷íîñòåé îñòàåòñÿ õèðóðãè÷åñêîå âìåøàòåëüñòâî. Âûñîêàÿ ýôôåêòèâíîñòü ïðèìåíåíèÿ õèðóðãè÷åñêîãî ìåòîäà, äîñòèãàåòñÿ ïðè ïîðàæåíèè ìàãèñòðàëüíûõ àðòåðèé, â òî æå âðåìÿ, ïðè ïîðàæåíèè äèñòàëüíûõ ñåãìåíòîâ ïåðèôåðè÷åñêèõ àðòåðèé (îáëèòåðèðóþùèé ýíäàðòåðèèò è òðîìáàíãèèò áîëåçíü Áþðãåðà) îïåðàòèâíîå ëå÷åíèå ìàëî ýôôåêòèâíî âñëåäñòâèå ïîâòîðíîãî îáðàçîâàíèÿ òðîìáîâ è ïîñëåäóþùåãî ñòåíîçèðîâàíèÿ. Îñíîâíûå óñèëèÿ õèðóðãîâ ïðè ëå÷åíèè òàêèõ çàáîëåâàíèé íàïðàâëåíû íà îáåñïå÷åíèå àäåêâàòíîãî ïðèòîêà êðîâè ê äèñòàëüíûì îòäåëàì êîíå÷íîñòè è ïîääåðæàíèÿ ýôôåêòèâíîé ïåðôóçèè òêàíåé. Ýòîãî ìîæíî äîñòè÷ü ïóòåì íåïðÿìîé ðåâàñêóëÿðèçàöèè. Ïîìèìî òðàäèöèîííûõ ìåòîäîâ ëå÷åíèÿ, òàêèõ êàê îñòåîòðåïàíàöèÿ è ïîÿñíè÷íàÿ ñèìïàòýêòîìèÿ, â ïîñëåäíåå âðåìÿ àêòèâíî èçó÷àåòñÿ âîçìîæíîñòü ïðèìåíåíèÿ êëåòî÷íûõ òåõíîëîãèé äëÿ ñîçäàíèÿ íîâûõ ïóòåé êîëëàòåðàëüíîãî êðîâîîáðàùåíèÿ â êîíå÷íîñòè. Òðàíñïëàíòàöèÿ áîëüíîìó åãî ñîáñòâåííûõ ñòâîëîâûõ êëåòîê ñòèìóëèðóåò àíãèîãåíåç â èøåìèçèðîâàííûõ òêàíÿõ. Ïðîâåäåííûå ýêñïåðèìåíòàëüíûå è êëèíè÷åñêèå èññëåäîâàíèÿ â ýòîé îáëàñòè ïîäòâåðæäàþò âûñîêóþ ýôôåêòèâíîñòü è áåçîïàñíîñòü òðàíñïëàíòàöèè ñòâîëîâûõ êëåòîê áîëüíûì ñ äàííîé ïàòîëîãèåé. Îäíàêî åñòü íåðàçðåøåííûå âîïðîñû, êàñàþùèåñÿ «êà÷åñòâà» è êîëè÷åñòâà êëåòîê, íåîáõîäèìûõ äëÿ îáðàçîâàíèÿ íîâûõ ñîñóäîâ. This article presents reviews application of cell technologies in the treatment of critical limb ischemia. Surgery treatment remains a basic method in the treatment of vascular obliterans limb diseases. In our days surgical methods are known as the most effective treatment of main artery atherosclerosis, but this kind of treatment is not so good for treatment peripheral arterial diseases such as thromboangitis obliterans (Buergers disease) because of often restenosis and rethrombosis development. Principal purpose efforts of surgeons according on ensuring of adequate blood flow in terminal parts of limb and also on support effective perfusion of tissue. This aim could be obtain due to undirected revascularization. Recently thanks to development of cells technologies on a level with osteothrepanation and lumbal sympathectomy it became possible to create new ways of roundabout blood flow in ischemic limb. Autological stem cells transplantation to patients with critical ischemic limb provides an appearance of new sites revascularization. In last years experimental and clinical studies in this area confirm safety and efficiency of the stem cells transplantation to patients with ischemic limb disease. However, few questions about quality and quantity of stem cells which are necessary for appearance revascularization remain unknown. Êëþ÷åâûå ñëîâà: òåðìèíàëüíàÿ ñòàäèÿ õðîíè÷åñêîé èøåìèè íèæíèõ êîíå÷íîñòåé, òðàíñïëàíòàöèÿ ñòâîëîâûõ êëåòîê, êîñòíûé ìîçã, ïðåäøåñòâåííèêè ýíäîòåëèîöèòîâ. Key words: critical limb ischemia, stem cells transplantation, bone morrow, endothelial progenitors. Êëèíè÷åñêàÿ êàðòèíà õðîíè÷åñêîé èøåìèè íèæíèõ êîíå÷íîñòåé ìîæåò áûòü îáóñëîâëåíà êàê èçîëèðîâàííûìè, òàê è ñî÷åòàííûìè îêêëþçèÿìè áðþøíîé àîðòû, åå áèôóðêàöèè, ïîäâçäîøíûõ è áåäðåííûõ àðòåðèé, à òàêæå àðòåðèé ãîëåíè è ñòîïû. Îñíîâíûìè ìîðôîëîãè÷åñêèìè ïðîÿâëåíèÿìè õðîíè÷åñêîé èøåìèè íèæíèõ êîíå÷íîñòåé ÿâëÿþòñÿ îáëèòåðèðóþùèé àòåðîñêëåðîç, ýíäàðòåðèèò è òðîìáàíãèèò (áîëåçíü Áþðãåðà).  òåðìèíàëüíîé ñòàäèè ýòèõ çàáîëåâàíèé ðàçâèâàåòñÿ ñîñòîÿíèå, èçâåñòíîå êàê «êðèòè÷åñêàÿ èøåìèÿ íèæíèõ êîíå÷íîñòåé» (ÊÈÍÊ) [1]. Ñîãëàñíî îïðåäåëåíèþ Ðîññèéñêîãî êîíñåíñóñà ïî äèàãíîñòèêå è ëå÷åíèþ ïàöèåíòîâ ñ êðèòè÷åñêîé èøåìèåé, European Consensus è Trans Atlantic Inter-Society Consensus (TASC), îñíîâíûìè êëèíè÷åñêèìè ïðèçíàêàìè ÊÈÍÊ ÿâëÿþòñÿ: íàëè÷èå õðîíè÷åñêîé àðòåðèàëüíîé íåäîñòàòî÷íîñòè íèæíèõ êîíå÷íîñòåé, ïîñòîÿííàÿ áîëü â ïîêîå, òðåáóþùàÿ îáåçáîëèâàíèÿ, â òå÷åíèå 2 íåäåëü è áîëåå, òðîôè÷åñêàÿ ÿçâà èëè ãàíãðåíà ïàëüöåâ èëè ñòîïû [2-4]. ÊÈÍÊ ñîîòâåòñòâóåò III Á è IV ñòàäèÿì èøåìèè ïî êëàññèôèêàöèè Ïîêðîâñêîãî-Ôîíòåéíà [4]. Îñíîâíûìè ôàêòîðàìè ðèñêà ðàçâèòèÿ îáñòðóêòèâíîãî ïîðàæåíèÿ ïåðèôåðè÷åñêèõ ñîñóäîâ ÿâëÿþòñÿ: êóðåíèå, ñàõàðíûé äèàáåò, ãèïåðõîëåñòåðèíåìèÿ, àðòåðèàëüíàÿ ãèïåðòåíçèÿ [4-6]. Ïî ðåçóëüòàòàì íàöèîíàëüíîãî èññëåäîâàíèÿ, ïðîâåäåííîãî Àíãèîëîãè÷åñêèì Ñîâåòîì Âåëèêîáðèòàíèè (1996-2006), ÷àñòîòà ÊÈÍÊ ñîñòàâëÿåò 400 áîëüíûõ íà 1 ìëí íàñåëåíèÿ â ãîä [7]. Åñëè ó÷åñòü, ÷òî 3% íàñåëåíèÿ ñòðàäàþò ïåðåìåæàþùåéñÿ õðîìîòîé è ó 5% èç íèõ â òå÷åíèå 5 ëåò ìîæåò ðàçâèòüñÿ ÊÈÍÊ, òî ÷àñòîòà ðàâíà 300 ñëó÷àåâ íà 1 ìëí íàñåëåíèÿ â ãîä. Îêîëî 90% âñåõ àìïóòàöèé âûïîëíÿåòñÿ ïî ïîâîäó âûðàæåííîé èøåìèè íèæíèõ êîíå÷íîñòåé. 25% ïàöèåíòîâ ñ ÊÈÍÊ ïðîâîäèòñÿ àìïóòàöèÿ êîíå÷íîñòè íà óðîâíå ãîëåíè èëè áåäðà [6]. Íàðàâíå ñ õàðàêòåðíûìè êëèíè÷åñêèìè ïðîÿâëåíèÿìè õðîíè÷åñêîé àðòåðèàëüíîé íåäîñòàòî÷íîñòè íèæíèõ êîíå÷íîñòåé (áîëü â ïîêîå, «ïåðåìåæàþùàÿñÿ õðîìîòà», áëåäíîñòü è ïîõîëîäàíèå êîæíûõ ïîêðîâîâ, òðîôè÷åñêèå íàðóøåíèÿ) ñóùåñòâóþò èíñòðóìåíòàëüíûå ìåòîäû äèàãíîñòèêè, ïîçâîëÿþùèå îáúåêòèâíî îöåíèòü óðîâåíü äåôèöèòà àðòåðèàëüíîãî êðîâîòîêà. Ïåðâîñòåïåííûì è íàèáîëåå âàæíûì ïîêàçàòåëåì, îáúåêòèâíî îöåíèâàþùèì ñîñòîÿíèå ãåìîäèíàìèêè ïðè ÊÈÍÊ, ÿâëÿåòñÿ ëîäûæå÷íî-ïëå÷åâîé èíäåêñ (ËÏÈ). Êëåòî÷íàÿ òðàíñïëàíòîëîãèÿ è òêàíåâàÿ èíæåíåðèÿ Òîì II, ¹ 3, 2007 Îáçîðû Íîðìàëüíûìè ñ÷èòàþòñÿ çíà÷åíèÿ ËÏÈ âûøå 0,9. Ïðè ÊÈÍÊ ëîäûæå÷íîå äàâëåíèå < 50 ìì ðò. ñò., ïàëüöåâîå äàâëåíèå < 30-50 ìì ðò. ñò., ËÏÈ < 0,4 [7]. Íåñìîòðÿ íà ïðîñòîòó â äèàãíîñòèêå ÊÈÍÊ, ëå÷åíèå ýòîãî ñîñòîÿíèÿ çà÷àñòóþ ñîïðîâîæäàåòñÿ îïðåäåëåííûìè òðóäíîñòÿìè. Áîëüíûå ñ âûñîêèì ðèñêîì ñåðäå÷íî-ñîñóäèñòûõ çàáîëåâàíèé - ýòî, êàê ïðàâèëî, ïîæèëûå è îñëàáëåííûå ëþäè. Ó ïàöèåíòîâ ñ ñàõàðíûì äèàáåòîì ÊÈÍÊ íàáëþäàåòñÿ ïðèìåðíî â ïÿòü ðàç ÷àùå, à òðîôè÷åñêèå íàðóøåíèÿ ðàçâèâàþòñÿ ó 10% ïàöèåíòîâ [11]. Âî âñåõ ñëó÷àÿõ îñíîâíîé öåëüþ ëå÷åíèÿ ÊÈÍÊ ÿâëÿåòñÿ ðåâàñêóëÿðèçàöèÿ òêàíåé. Îíà ìîæåò áûòü äîñòèãíóòà ïóòåì ôîðìèðîâàíèÿ øóíòà «â îáõîä» ìåñòà îêêëþçèè ñîñóäà, ëèáî àíãèîïëàñòèêîé (òðîìáýíäàðòåðýêòîìèÿ, ñòåíòèðîâàíèå è áàëëîííàÿ äèëàòàöèÿ ïðîñâåòà ñîñóäà, ëàçåðíàÿ àáëÿöèÿ àòåðîñêëåðîòè÷åñêèõ áëÿøåê è äð.) [3, 8-11]. Àíàëèç äàííûõ, ïîëó÷åííûõ ïîñëå øóíòèðóþùèõ îïåðàöèé è ÷ðåñêîæíîé òðàíñëþìèíàëüíîé àíãèîïëàñòèêè, íå âûÿâèë çíà÷èìûõ ðàçëè÷èé â ëåòàëüíîñòè [12]. Ëåòàëüíîñòü ïîñëå ðåêîíñòðóêòèâíûõ îïåðàöèé ñîñòàâëÿåò 2-13%, à ÷àñòîòà àìïóòàöèé - äî 10%.  ñðîêè äî 10 ëåò ïðîõîäèìîñòü ñîñóäèñòûõ ïðîòåçîâ ñîõðàíÿåòñÿ â àîðòî-ïîäâçäîøíîì ñåãìåíòå ó 80-90% ïàöèåíòîâ. Ðåçóëüòàòû âíåïîëîñòíûõ îïåðàöèé õóæå: ÷åðåç 3 ãîäà ïðîõîäèìû 60-70% áåäðåííî-áåäðåííûõ øóíòîâ è 64% ïîäìûøå÷íîáåäðåííûõ øóíòîâ [13]. Ïî äàííûì Ñîãëàñèòåëüíîãî äîêóìåíòà Ðîññèéñêîãî îáùåñòâà ñåðäå÷íî-ñîñóäèñòûõ õèðóðãîâ, ïðè ÊÈÍÊ ÷åðåç 1 ãîä ïîñëå áåäðåííî-ïîäêîëåííîãî øóíòèðîâàíèÿ àóòîëîãè÷íîé âåíîé ñîõðàíÿåòñÿ ïðîõîäèìîñòü 75% øóíòîâ, ïðîòåçîì 65%. Ïîñëå áåäðåííî-òèáèàëüíîãî øóíòèðîâàíèÿ àóòîëîãè÷íîé âåíîé ñîõðàíÿåòñÿ ïðîõîäèìîñòü 70% øóíòîâ è 40% ïðîòåçîâ. Ðåçóëüòàòû àíãèîïëàñòèêè ïîêàçûâàþò, ÷òî ÷åðåç 2 ãîäà ïðîõîäèìû 85% ïîäâçäîøíûõ àðòåðèé è ëèøü 50% áåäðåííûõ è ïîäêîëåííûõ àðòåðèé. Ñèòóàöèÿ îñëîæíÿåòñÿ åùå è òåì, ÷òî ÊÈÍÊ â áîëüøèíñòâå ñëó÷àåâ îáóñëîâëåíà òÿæåëûì è äèôôóçíûì ïîðàæåíèåì ïåðèôåðè÷åñêèõ àðòåðèé êîíå÷íîñòè, ÷àñòî ñî÷åòàþùèìñÿ ñ âûðàæåííûì äåôèöèòîì êðîâîòîêà íà óðîâíå ìèêðîöèðêóëÿòîðíîãî ðóñëà.  óñëîâèÿõ ïîðàæåíèÿ äèñòàëüíîãî ñåãìåíòà êîíå÷íîñòè è ìèêðîàíãèîïàòèè, à òàêæå ïðè íåýôôåêòèâíîñòè ðàíåå ïðîâåäåííîé ðåâàñêóëÿðèçàöèè, ìåäèêàìåíòîçíîå ëå÷åíèå îñòàåòñÿ åäèíñòâåííûì äîñòóïíûì âàðèàíòîì ëå÷åíèÿ äî àìïóòàöèè. Ó ïàöèåíòîâ ñ ÊÈÍÊ ïðè îòñóòñòâèè óñëîâèé äëÿ «ïðÿìîé» ðåâàñêóëÿðèçàöèè ñòàíäàðòíàÿ êîíñåðâàòèâíàÿ òåðàïèÿ ìàëîýôôåêòèâíà.  áëèæàéøèå ñðîêè îò íà÷àëà ëå÷åíèÿ ïîëîæèòåëüíûé ðåçóëüòàò îòìå÷àåòñÿ ëèøü ó ïîëîâèíû ïàöèåíòîâ, à 1/3 ïàöèåíòîâ ÿâëÿþòñÿ êàíäèäàòàìè íà àìïóòàöèþ. Îäíîëåòíÿÿ âûæèâàåìîñòü áîëüíûõ, ïåðåíåñøèõ àìïóòàöèþ íà óðîâíå ãîëåíè, ñîñòàâëÿåò îêîëî 30%. Ñìåðòíîñòü îñòàåòñÿ ãëàâíîé ïðîáëåìîé â ýòîé ãðóïïå ïàöèåíòîâ, 3040% èç íèõ æèâóò ìåíåå 5 ëåò, à ïðè ÊÈÍÊ, ñî÷åòàþùåéñÿ ñ ÿçâàìè èëè ãàíãðåíîé, ïðîöåíò ëåòàëüíîñòè åùå âûøå [9]. Ïî äàííûì TASC, ñðåäè ïàöèåíòîâ ñ ÊÈÍÊ îò 10 äî 30% æèâóò íå áîëåå 6 ìåñÿöåâ, à 25-30% ïàöèåíòîâ ìîæåò ïîòðåáîâàòüñÿ «ìàññèâíàÿ» àìïóòàöèÿ [3]. Ïðîãíîç ïîñëå àìïóòàöèè òàêæå íåóòåøèòåëåí: ðàííÿÿ ïîñëåîïåðàöèîííàÿ ëåòàëüíîñòü ñîñòàâëÿåò îêîëî 5-10% ïîñëå àìïóòàöèè íà óðîâíå ãîëåíè, è 15-20% ïîñëå àìïóòàöèè íà óðîâíå áåäðà. Èç ïàöèåíòîâ, ïåðåíåñøèõ îïåðàöèþ, îêîëî 30% óìèðàþò â áëèæàéøèå 2 ãîäà. Ïîâòîðíàÿ àìïóòàöèÿ òðåáóåòñÿ 1/3 áîëüíûõ. Ïîëíàÿ ðåàáèëèòàöèÿ ìîæåò áûòü äîñòèãíóòà ìåíåå, ÷åì ó ïîëîâèíû èç íèõ [2, 14]. Áîëüøîå âíèìàíèå â íàñòîÿùåå âðåìÿ óäåëÿåòñÿ îïðåäåëåíèþ ìåñòà íåïðÿìûõ ìåòîäîâ ðåâàñêóëÿðèçàöèè â ëå÷åíèè ÊÈÍÊ. Íàèáîëåå ÷àñòî èñïîëüçóåìûìè îïåðàöèÿìè ÿâëÿþòñÿ ïîÿñíè÷íàÿ ñèìïàòýêòîìèÿ (ÏÑÝ) è ðåâàñêóëÿðèçèðóþùàÿ 41 îñòåîòðåïàíàöèÿ.  êà÷åñòâå ñàìîñòîÿòåëüíûõ ìåòîäîâ ëå÷åíèÿ îíè èñïîëüçóþòñÿ òîëüêî ïðè íåâîçìîæíîñòè âûïîëíåíèÿ ïðÿìûõ ðåêîíñòðóêòèâíûõ âìåøàòåëüñòâ.  áëèæàéøèé ïîñëåîïåðàöèîííûé ïåðèîä ÏÑÝ ýôôåêòèâíàÿ ó 45% ïàöèåíòîâ, à ñïóñòÿ 4 ãîäà îíà ïîçâîëÿåò ñîõðàíèòü êîíå÷íîñòü ëèøü ó 35% ïàöèåíòîâ. Ïîëîæèòåëüíûé ýôôåêò ïðè ïðîâåäåíèè îñòåîòðåïàíàöèè íàáëþäàåòñÿ â 28% ñëó÷àåâ, ó 50% èç êîòîðûõ ñîõðàííîñòü êîíå÷íîñòåé íàáëþäàåòñÿ ñïóñòÿ 4 ãîäà. Íåñêîëüêî ëó÷øèå ðåçóëüòàòû íàáëþäàþòñÿ ïðè ñî÷åòàíèè îáåèõ ìåòîäèê: ñïóñòÿ 4 ãîäà óäàåòñÿ ñîõðàíèòü êîíå÷íîñòü áîëåå ÷åì ó 60% ïàöèåíòîâ [15]. Ñî÷åòàíèå ìåòîäîâ íåïðÿìîé ðåâàñêóëÿðèçàöèè ñ ðåêîíñòðóêòèâíûìè îïåðàöèÿìè (îñîáåííî â ñëó÷àå ïîâòîðíîãî èõ âûïîëíåíèÿ) òàêæå äàåò õîðîøèé òåðàïåâòè÷åñêèé ýôôåêò [16]. Ïðîäîëæàåòñÿ ïîèñê àëüòåðíàòèâíûõ ïóòåé ðåâàñêóëÿðèçàöèè èøåìèçèðîâàííûõ òêàíåé. Îäíèì èç ïóòåé ñòèìóëÿöèè íåîàíãèîãåíåçà ìîæåò áûòü ïðèìåíåíèå êëåòî÷íûõ è ãåííûõ òåõíîëîãèé [16]. Áèîëîãè÷åñêèå è ïàòîôèçèîëîãè÷åñêèå îñíîâû êëåòî÷íîé òåðàïèè êðèòè÷åñêîé èøåìèè íèæíèõ êîíå÷íîñòåé  ïîñëåäíåå âðåìÿ áûëè ïðîâåäåíû èññëåäîâàíèÿ, êîòîðûå ïîêàçàëè, ÷òî îáðàçîâàíèå êðîâåíîñíûõ ñîñóäîâ â ïîñòíàòàëüíîì ïåðèîäå îáóñëîâëåíî íàëè÷èåì êëåòîêïðåäøåñòâåííèêîâ ýíäîòåëèàëüíûõ êëåòîê (ÝÊ) â ñòåíêàõ ñîñóäîâ [7]. Åñòü âñå îñíîâàíèÿ ïîëàãàòü, ÷òî ýòè êëåòêèïðåäøåñòâåííèêè ìîãóò ñîõðàíÿòüñÿ íà ïðîòÿæåíèè âñåé æèçíè îðãàíèçìà è ïðèíèìàòü ó÷àñòèå â îáíîâëåíèè ñîñóäîâ [17-19]. Ôîðìèðîâàíèå íîâûõ ñîñóäîâ íåîàíãèîãåíåç, âî âçðîñëîì îðãàíèçìå ðàññìàòðèâàåòñÿ êàê ðåçóëüòàò ïðîëèôåðàöèè, ìèãðàöèè è ðåìîäåëèðîâàíèÿ óæå èìåþùèõñÿ çðåëûõ ÝÊ [20].  íåîâàñêóëÿðèçàöèè ó÷àñòâóþò ïðåäøåñòâåííèêè ýíäîòåëèîöèòîâ (ÏÝ) CD34+ ôðàêöèè ñòâîëîâûõ êëåòîê ïåðèôåðè÷åñêîé êðîâè âçðîñëûõ ïîñëå èõ ìîáèëèçàöèè èç êîñòíîãî ìîçãà (ÊÌ) [7, 19, 21, 22] (ðèñ. 1).  ýòîì êîíòåêñòå, òåðàïåâòè÷åñêèé íåîàíãèîãåíåç ïðåäñòàâëÿåòñÿ âàæíîé ñòðàòåãèåé ñïàñåíèÿ òêàíåé ïðè ÊÈÍÊ [23-26]. Áûñòðàÿ ðåâàñêóëÿðèçàöèÿ â ïîâðåæäåííûõ (èøåìèçèðîâàííûõ) è â ðåãåíåðèðóþùèõ îðãàíàõ ÷ðåçâû÷àéíî âàæíà äëÿ âîññòàíîâëåíèÿ ôóíêöèé. Ñîñóäèñòàÿ òðàâìà èëè èøåìèÿ òêàíåé àêòèâèðóåò êàñêàä ìîëåêóëÿðíî-ãåíåòè÷åñêèõ ðåàêöèé, ãëàâíûì ðåçóëüòàòîì êîòîðûõ ÿâëÿåòñÿ ìîáèëèçàöèÿ èç ÊÌ è äðóãèõ èñòî÷íèêîâ ïðåäøåñòâåííèêîâ ýíäîòåëèàëüíûõ êëåòîê, îáåñïå÷èâàþùèõ ðåâàñêóëÿðèçàöèþ çà ñ÷åò îáðàçîâàíèÿ íîâûõ ñîñóäèñòûõ ôîðìàöèé [25-31]. Ïðîâåäåííûå èññëåäîâàíèÿ ïîêàçàëè, ÷òî êëåòêè ÊÌ ó÷àñòâóþò â íåîàíãèîãåíåçå ïðè çàæèâëåíèè ðàí [31-41] è èøåìèè íèæíèõ êîíå÷íîñòåé [31, 32], ýíäîòåëèçàöèè ñîñóäèñòûõ ïðîòåçîâ [42-45], ïðè àòåðîñêëåðîçå [7, 46], âàñêóëÿðèçàöèè â ïåðèîä ïîñòíàòàëüíîãî ðîñòà [47] è ïðè îïóõîëåâîì ðîñòå [33, 48-52]. Ýòè èññëåäîâàíèÿ ñâèäåòåëüñòâóþò, ÷òî âî âðåìÿ ïîâðåæäåíèÿ ñîñóäîâ èëè ðåãåíåðàöèè îðãàíà, ïðîèñõîäèò âûñâîáîæäåíèå öèòîêèíîâ, êîòîðûå îïîñðåäóþò ìèãðàöèþ ÏÝ è öèðêóëèðóþùèõ ýíäîòåëèàëüíûõ êëåòîê (ÖÝÊ) â çîíó íåîàíãèîãåíåçà. Íàïðèìåð, òêàíåâàÿ èøåìèÿ ïðèâîäèò ê âêëþ÷åíèþ ñîñóäèñòûõ ôàêòîðîâ, òàêèõ êàê ñîñóäèñòûé ýíäîòåëèàëüíûé ôàêòîð ðîñòà (VEGF), êîòîðûé, ñâÿçûâàÿñü ñ ðåöåïòîðàìè (VEGF-R2 è VEGF-R1) êëåòîê, ó÷àñòâóþùèõ â íåîàíãèîãåíåçå, îáåñïå÷èâàåò ìèãðàöèþ ïîñëåäíèõ â çîíó ïîâðåæäåíèÿ. Áûñòðîå âíåäðåíèå êëåòîê â çîíó íåîàíãèîãåíåçà óñêîðÿåò âîññòàíîâëåíèå ñîñóäîâ, ïîçâîëÿåò èçáåæàòü ïîòåíöèàëüíûõ ñîñóäèñòûõ îñëîæíåíèé: âòîðè÷íîãî òðîìáîçà è ãèïîêñèè. Êëåòî÷íàÿ òðàíñïëàíòîëîãèÿ è òêàíåâàÿ èíæåíåðèÿ Òîì II, ¹ 3, 2007 42 Îáçîðû Èøåìè÷åñêèé îðãàí Ñèíóñîèäàëüíûå ñîñóäû Ìîáèëèçàöèÿ Êðîâåíîñíûå ñîñóäû Ñòâîëîâûå êëåòêè è è êëåòêè-ïðåäøåñòâåííèêè Ëèìôàòè÷åñêèå ñîñóäû CEPs Ñîñóäèñòàÿ çîíà Îñòåîáëàñòíàÿ çîíà Êîñòíûé ìîçã Ìèåëîèäíûå è ëèìôîèäíûå êëåòêè VEGF-A PLGF VEGFR1+ Sca-1+ c-Kit+ êëåòêè VEGFR2+ c-Kit+ EPCs VEGFR3+ êëåòêè-ïðåäøåñòâåííèêè ëèìôîèäíîãî ðîñòêà cKitL mKitL MMP-9↑ ↑ Êëåòêè ñòðîìû Ðèñ. 1. Ìåæêëåòî÷íûå âçàèìîîòíîøåíèÿ è ìîëåêóëÿðíûå ìåõàíèçìû ìîáèëèçàöèè ýíäîòåëèàëüíûõ, ëèìôàòè÷åñêèõ, ñòâîëîâûõ ãåìàòîïîýòè÷åñêèõ è ïðîãåíèòîðíûõ êëåòîê. Ïîâðåæäåíèå ñòåíêè ñîñóäà ïðèâîäèò ê ïîâûøåíèþ óðîâíÿ ñîñóäèñòûõ ôàêòîðîâ ðîñòà, âêëþ÷àÿ VEGF-A è PLGF, êîòîðûå àêòèâèðóþò MMP-9. MMP-9 óñèëèâàåò áèîäîñòóïíîñòü öèòîêèíîâ, àêòèâíûõ â îòíîøåíèè ñòâîëîâûõ êëåòîê, sKit-ëèãàíäà, àêòèâèðóåò öèðêóëÿöèþ è ïðîëèôåðàöèþ VEGF-R1+c-Kit+ ãåìàòîïîýòè÷åñêèõ êëåòîê, VEGF-R3+ ëèìôîöèòîâ è VEGF-R2+c-Kit+ êëåòîê-ïðåäøåñòâåííèêîâ ýíäîòåëèîöèòîâ. Óâåëè÷åíèå êîëè÷åñòâà öèðêóëèðóþùèõ ñòâîëîâûõ êëåòîê ïðèâîäèò ê ïîÿâëåíèþ êëåòîê-ïðåäøåñòâåííèêîâ â çîíàõ àíãèîãåíåçà. Ñîäðóæåñòâåííàÿ ìîáèëèçàöèÿ ïðîàíãèîãåííûõ VEGF-R1+ ñòâîëîâûõ ãåìàòîïîýòè÷åñêèõ êëåòîê-ïðåäøåñòâåííèêîâ ìîæåò óñèëèâàòü ôóíêöèîíàëüíîå âíåäðåíèå VEGF-R2+ êëåòîê-ïðåäøåñòâåííèêîâ ýíäîòåëèîöèòîâ â çîíû àíãèîãåíåçà. Syk+ and SLP-76+ ãåìàòîïîýòè÷åñêèå êëåòêè ó÷àñòâóþò ïðîöåññàõ ðåãóëÿöèè îáðàçîâàíèÿ êðîâåíîñíûõ è ëèìôàòè÷åñêèõ ñîñóäîâ  íàñòîÿùåå âðåìÿ àêòèâíî ðàçðàáàòûâàþòñÿ òåõíîëîãèè ïîëó÷åíèÿ ñîñóäèñòûõ ôàêòîðîâ, êîòîðûå ñïîñîáíû óñêîðÿòü ïðîöåññû ðåâàñêóëÿðèçàöèè òêàíåé [52-59]. Ïàòîëîãè÷åñêèå èçìåíåíèÿ â ñîñóäàõ è â òêàíÿõ â áîëüøèíñòâå ñëó÷àåâ îáóñëîâëåíû íåäîñòàòî÷íûì êîëè÷åñòâîì â çîíå ïîâðåæäåíèÿ ðåçåðâíûõ ÝÊ, êîòîðûå â íîðìå ñïîñîáíû ñàìîñòîÿòåëüíî âîññòàíàâëèâàòü âàñêóëÿðèçàöèþ (ñì. ðèñ. 1). Òàêèì îáðàçîì, ïîÿâèëàñü ïîòðåáíîñòü â äîïîëíèòåëüíûõ ôàêòîðàõ, ñïîñîáíûõ âîññòàíîâèòü âàñêóëÿðèçàöèþ. Íà ðîëü îäíîãî èç òàêèõ ôàêòîðîâ ìîãóò ïðåòåíäîâàòü ÏÝ. Èññëåäîâàíèÿ ïîñëåäíèõ ëåò äîêàçàëè, ÷òî â ÊÌ íàõîäÿòñÿ ñîñóäèñòûå ïðîãåíèòîðíûå êëåòêè, êîòîðûå ìîãóò ïîñòóïàòü â çîíó èøåìèè è ïðèíèìàòü ó÷àñòèå â ïðîöåññàõ ðåâàñêóëÿðèçàöèè [5]. Ó÷àñòèå êëåòîê êîñòíîãî ìîçãà â àòåðîñêëåðîçå è àðòåðèîñêëåðîçå Ïàòîëîãè÷åñêàÿ ïðîëèôåðàöèÿ ãëàäêîìûøå÷íûõ êëåòîê (ÃÌÊ) ïðèâîäèò ê èçìåíåíèÿì èíòèìû, ñóùåñòâóþùåé äî ôîðìèðîâàíèÿ àòåðîìàòîçíîé áëÿøêè, ðåñòåíîçà ïîñëå àíãèîïëàñòèêè, à òðàíñïëàíòàöèÿ ïðèâîäèò ê çàâèñèìîé âàñêóëîïàòèè. Îïûòû íà æèâîòíûõ äîêàçàëè, ÷òî ãåìîïîýòè÷åñêèå êëåòêè ôåíîòèïà Sca1+cKit+Lin- äèôôåðåíöèðóþòñÿ â ÃÌÊ è ó÷àñòâóþò â ðåñòåíîçå ïîñëå àíãèîïëàñòèêè, âàñêóëîïàòèè ïðîòåçà è Êëåòî÷íàÿ òðàíñïëàíòîëîãèÿ è òêàíåâàÿ èíæåíåðèÿ Òîì II, ¹ 3, 2007 àòåðîñêëåðîçå [85]. Ìåõàíè÷åñêîå ïîâðåæäåíèå áåäðåííîé àðòåðèè òàêæå ïðèâîäèò ê ìîáèëèçàöèè êëåòîê êîñòíîãî ìîçãà, îòâå÷àþùèõ çà ïðîëèôåðàöèþ ÃÌÊ. Ïîëó÷åíû äîêàçàòåëüñòâà ó÷àñòèÿ êëåòîê ÊÌ â îáðàçîâàíèè àòåðîìàòîçíûõ áëÿøåê â ñîñóäàõ ÷åëîâåêà [86]. Ðåêðóòèíã ÝÊ è ÃÌÊ èç êîñòíîãî ìîçãà ëèáî èç äîíîðñêîãî òðàíñïëàíòàòà çàâèñèò îò îñíîâíîé èìåþùåéñÿ ïàòîëîãèè. Íà ìîäåëÿõ àòåðîñêëåðîòè÷åñêîãî ïîðàæåíèÿ ñîñóäèñòîãî ïðîòåçà áîëüøèíñòâî ÝÊ è ÃÌÊ áûëè âûäåëåíû èç ñîñóäîâ õîçÿèíà ñ ìèíèìàëüíûì ó÷àñòèåì ïðîãåíèòîðîâ ÊÌ [88]. Îäíàêî ñòåïåíü ó÷àñòèÿ êëåòîê ÊÌ ìîæåò âàðüèðîâàòü â çàâèñèìîñòè îò òÿæåñòè ñîñóäèñòîé òðàâìû [93]. Ìåõàíè÷åñêàÿ òðàâìà ñîñóäà ïðèâîäèò ê ãëóáîêîìó ïðîíèêíîâåíèþ êëåòîê ÊÌ â ïîâðåæäåííóþ èíòèìó. Êàæäûé èíñóëüò ïðèâîäèò ê âûñâîáîæäåíèþ ñïåöèôè÷åñêèõ ôàêòîðîâ, êîòîðûå ñïîñîáñòâóþò ãèïåðïëàçèè èíòèìû. Ýòî âîçìîæíî ïðè òÿæåëîé ñîñóäèñòîé òðàâìå è â ñëó÷àå èììóíî-îïîñðåäîâàííîé òðàíñïëàíòàöèîííîé âàñêóëîïàòèè [87], ïðèâîäÿùåé ê âûñâîáîæäåíèþ öèòîêèíîâ, êîòîðûå èíäóöèðóþò ìîáèëèçàöèþ êëåòîê ÊÌ. Áûëè èçó÷åíû âîçìîæíîñòè êëåòîê ëèíèè Sca1+cKit+Lin- äèôôåðåíöèðîâàòüñÿ â ðàçíûå òêàíè, âêëþ÷àÿ ÝÊ è ÃÌÊ [89, 94, 95]. Îäíàêî, äëÿ ïîäòâåðæäåíèÿ ó÷àñòèÿ êëåòîê ÊÌ â îáðàçîâàíèè ôóíêöèîíàëüíî ïîëíîöåííûõ àðòåðèé íåîáõîäèìî ïðîâåäåíèå äîïîëíèòåëüíûõ èññëåäîâàíèé. 43 Îáçîðû Ðîëü ïðåäøåñòâåííèêîâ ýíäîòåëèîöèòîâ â âàñêóëÿðèçàöèè òêàíåé Äî èìïëàíòàöèè 24 íåäåëè ïîñëå Îáíîâëåíèå ñîñóäîâ ïðîèñõîäèò ïîñðåäñòâîì ìîáèëèçàöèè ÏÝ è ÖÏÝ. Èññëåäîâàíèÿìè, âûïîëíåííûìè ìîëåêóëÿðíî-ãåíåòè÷åñêèìè ìåòîäàìè, äîêàçàëè âîçìîæíîñòü ïîñòóïëåíèÿ ÏÝ ÊÌ â èøåìèçèðîâàííûå êîíå÷íîñòè ìûøåé [19, 39, 66]. Äðóãèå èññëåäîâàíèÿ ïîêàçàëè, ÷òî òðàíñïëàíòàöèÿ çðåëûõ ýíäîòåëèîöèòîâ, ïîëó÷åííûõ ïðè êóëüòèâèðîâàíèè in vitro ìóëüòèïîòåíòíûõ ïðåäøåñòâåííèêîâ ñòâîëîâûõ êëåòîê âçðîñëîãî îðãàíèçìà, âûäåëåííûõ èç êîñòíîãî ìîçãà, çíà÷èòåëüíî óñêîðÿåò ïðîöåññû ðåâàñêóëÿðèçàöèè òêàíÿõ [22, 67]. Çàñëóæèâàåò âíèìàíèå ýêñïåðèìåíòàëüíàÿ ðàáîòà ïî çàìåùåíèþ ó âçðîñëîé ñîáàêè ãðóäíîãî îòäåëà àîðòû äàêðîíîâûì ïðîòåçîì. Ïåðåä ïðîòåçèðîâàíèåì ñîáàêå âûïîëíÿëàñü ïåðåñàäêà àëëîãåííîãî êîñòíîãî ìîçãà. ×åðåç 3 ìåñÿöà â ïðîòåçå îïðåäåëÿëñÿ ðîñò ýíäîòåëèàëüíûõ êëåòîê [43, 66]. Óìåíüøåíèå ñîäåðæàíèÿ ÖÝÊ â êðîâîòîêå êîððåëèðóåò ñ âûñîêèì óðîâíåì ñåðäå÷íî-ñîñóäèñòûõ îñëîæíåíèé [87]. J. Hill et al. (2003) ïðåäïîëîæèëè, ÷òî ñíèæåíèå óðîâíÿ ÖÝÊ óõóäøàåò âîññòàíîâëåíèå ïîâðåæäåííûõ ñîñóäîâ [85]. Îäíàêî ïàòîôèçèîëîãè÷åñêàÿ ðîëü ÖÝÊ ÊÌ äî ñèõ ïîð íå îïðåäåëåíà. Òðàíñïëàíòàöèÿ êëåòîê êîñòíîãî ìîçãà â ëå÷åíèè êðèòè÷åñêîé èøåìèè íèæíèõ êîíå÷íîñòåé  ýêñïåðèìåíòàëüíûõ ìîäåëÿõ ÊÈÍÊ äëÿ íåîàíãèîãåíåçà áûëè èñïîëüçîâàíû ðàçëè÷íûå òèïû êëåòîê. Èññëåäîâàíèÿ ïîêàçàëè, ÷òî â àíãèîãåíåçå ìîãóò ó÷àñòâîâàòü ìîíîíóêëåàðíûå êëåòêè (ÌÍÊ) ÊÌ [58, 63], ãåìîïîýòè÷åñêèå ñòâîëîâûå êëåòêè (ÃÑÊ) [72-74], ìîáèëèçîâàííûå ýíäîòåëèàëüíûå ïðîãåíèòîðíûå êëåòêè [19, 39, 77], êëåòêè ñòðîìû êîñòíîãî ìîçãà [75], ñòâîëîâûå êëåòêè, âûäåëåííûå èç æèðîâîé òêàíè [76].  äîêëèíè÷åñêèõ èññëåäîâàíèÿõ ââåäåíèå ïðåäøåñòâåííèêîâ ýíäîòåëèîöèòîâ óñêîðÿëî ôîðìèðîâàíèå êîëëàòåðàëüíûõ ñîñóäîâ, ìèíèìèçèðóÿ ïðè ýòîì çîíó èøåìè÷åñêîãî ïîâðåæäåíèÿ [58, 60, 63]. Ìåõàíèçìû ó÷àñòèÿ ÏÝ â âàñêóëÿðèçàöèè òêàíåé ÷åëîâåêà îêîí÷àòåëüíî íå èçó÷åíû. Îñíîâíàÿ ïðè÷èíà òðóäíîñòè â âûäåëåíèè è ðàñïîçíàâàíèè ÏÝ è ÖÝÊ âñëåäñòâèå îòñóòñòâèÿ ñïåöèôè÷åñêèõ ýíäîòåëèàëüíûõ ìàðêåðîâ è íåâîçìîæíîñòè îòëè÷èòü ýòè êëåòêè îò çðåëûõ ýíäîòåëèîöèòîâ ñîñóäèñòîé ñòåíêè. Áîëåå òîãî, ïîäãðóïïà ìèåëî-ìîíîöèòàðíûõ êëåòîê ìîæåò áûòü íåïðàâèëüíî èíòåðïðåòèðîâàíà êàê ÏÝ èëè ÖÝÊ, ïîñêîëüêó îíè òîæå ýêñïðåññèðóþò ýíäîòåëèé-ñïåöèôè÷åñêèå àíòèãåíû [90, 91]. ÏÝ, âûäåëåííûå èç êîñòíîãî ìîçãà, ÖÝÊ è çðåëûå ýíäîòåëèîöèòû, âûäåëåííûå èç ñîñóäèñòîé ñòåíêè, ýêñïðåññèðóþò ñõîæèå ýíäîòåëèé-ñïåöèôè÷íûå ìàðêåðû, âêëþ÷àÿ VEGF-R2, Tie-2, ñîñóäèñòûé ýíäîòåëèàëüíûé êàäãåðèí (VE-cadgerin), CD34+, CD146+ è E-ñåëåêòèí [19, 39, 41, 91, 92]. Ðàçëè÷èå ìåæäó ÏÝ, ÖÝÊ è ÝÊ òàêæå îñëîæíÿåòñÿ òåì, ÷òî ÃÑÊ ýêñïðåññèðóþò ìàðêåðû, ñõîäíûå ñ òåìè, êîòîðûå ýêñïðåññèðóþò ÝÊ, âêëþ÷àÿ CD34+, PECAM (CD31+), Tie-2, ôàêòîð Âèëëèáðàíäà è VEGF-R1. Ïðîâåäåííûå êëèíè÷åñêèå èññëåäîâàíèÿ îïðåäåëèëè âûñîêèé ïîòåíöèàë êëåòîê ÊÌ â âîññòàíîâëåíèè âàñêóëÿðèçàöèè èøåìèçèðîâàííûõ òêàíåé (ðèñ. 2, ðèñ. 3) [33, 59, 61-63, 81]. Óñïåõ ýòîé ñòðàòåãèè çàâèñèò îò îïðåäåëåíèÿ ìåõàíèçìîâ, ïîñðåäñòâîì êîòîðûõ ñòâîëîâûå è ïðîãåíèòîðíûå êëåòêè ïðîõîäÿò ìîëåêóëÿðíûå ïåðåñòðîéêè, íåîáõîäèìûå äëÿ èõ íàïðàâëåííîé ïðîëèôåðàöèè, ìîáèëèçàöèè è äèôôåðåíöèðîâêè, è òåì ñàìûì îïðåäåëÿåòñÿ èõ ôóíêöèîíàëüíîå ïîâåäåíèå â òêàíÿõ âçðîñëîãî îðãàíèçìà. Ðèñ. 2. Àíãèîãðàììû áîëüíîãî ñ ïîðàæåíèåì äèñòàëüíûõ ñîñóäîâ íèæíåé êîíå÷íîñòè äî è ïîñëå (÷åðåç 24 íåäåëè) èìïëàíòàöèè ìîíîíóêëåàðíûõ êëåòîê, âûäåëåííûõ èç êîñòíîãî ìîçãà. Ââåäåíèå ìîíîíóêëåàðíûõ êëåòîê ñòèìóëèðóåò àíãèîãåíåç â òêàíÿõ íèæíåé êîíå÷íîñòè Äî èìïëàíòàöèè 8 íåäåëü ïîñëå Ðèñ. 3. Ïðèìåð çàæèâëåíèÿ äëèòåëüíî ñóùåñòâóþùèõ òðîôè÷åñêèõ ÿçâ ïîñëå ïðîâåäåíèÿ êëåòî÷íîé òðàíñïëàíòàöèè àóòîëîãè÷íûìè ìîíîíóêëåàðíûìè êëåòêàìè, âûäåëåííûìè èç êîñòíîãî ìîçãà áîëüíîãî ñ êðèòè÷åñêîé èøåìèåé íèæíèõ êîíå÷íîñòåé Êëåòî÷íàÿ òðàíñïëàíòîëîãèÿ è òêàíåâàÿ èíæåíåðèÿ Òîì II, ¹ 3, 2007 44 Îáçîðû Ïåðâîå êëèíè÷åñêîå èññëåäîâàíèå ïî ïðèìåíåíèþ ñòâîëîâûõ êëåòîê â ëå÷åíèè ÊÈÍÊ îïóáëèêîâàíî â 2002 ã. Å. Tateishi-Yuyama et al., êîòîðûå èññëåäîâàëè ýôôåêòèâíîñòü è áåçîïàñíîñòü èìïëàíòàöèè àóòîëîãè÷íûõ ÌÍÊ èç ÊÌ áîëüíûì ñ ÊÈÍÊ [67]. Ïîä îáùåé àíåñòåçèåé îíè àñïèðèðîâàëè 500,0 ìë ÊÌ èç ãðåáíÿ ïîäâçäîøíîé êîñòè. ×åðåç 3 ÷àñà ïîñëå àñïèðàöèè ôðàêöèÿ èçîëèðîâàííûõ ÌÍÊ áûëà ââåäåíà â èêðîíîæíûå ìûøöû ïîñðåäñòâîì 40 èíúåêöèé ïî 0,75 ìë. Êîëè÷åñòâî ââåäåííûõ êëåòîê ñîñòàâèëî 0,7-2,8×109. Ïàöèåíòîâ ðàçäåëèëè íà 2 ãðóïïû. Ïåðâîé ãðóïïå ââîäèëè ÌÍÊ, âûäåëåííûå èç ÊÌ, âòîðîé ãðóïïå ââîäèëè ÌÍÊ, âûäåëåííûå èç ÊÌ, â ìûøöû îäíîé êîíå÷íîñòè, à â ìûøöû äðóãîé êîíå÷íîñòè ââîäèëè ÃÑÊ ïîñëå ñòèìóëÿöèè G-CSF. Ðåçóëüòàòîì ëå÷åíèÿ ÷åðåç 4 íåäåëè áûëî ïîÿâëåíèå êîëëàòåðàëåé, ïîâûøåíèå ÷ðåçêîæíîãî íàïðÿæåíèÿ êèñëîðîäà, óìåíüøåíèå áîëåé è óâåëè÷åíèå âðåìåíè õîäüáû äî ïîÿâëåíèÿ áîëåé. Âî âòîðîé ãðóïïå çíà÷èòåëüíîå óëó÷øåíèå ïåðå÷èñëåííûõ ïàðàìåòðîâ áûëî â îáëàñòè ââåäåíèÿ ÌÍÊ ÊÌ. Îñëîæíåíèé, ñâÿçàííûõ ñ ïðîâåäåííûì ëå÷åíèåì, îòìå÷åíî íå áûëî. Èññëåäîâàíèå ïîêàçàëî, ÷òî òðàíñïëàíòàöèÿ àóòîëîãè÷íûõ ÌÍÊ ÊÌ ÿâëÿåòñÿ áåçîïàñíîé è ýôôåêòèâíîé ïðîöåäóðîé äëÿ ïðîâåäåíèÿ òåðàïåâòè÷åñêîãî àíãèîãåíåçà.  äâóõ äðóãèõ èññëåäîâàíèÿõ ïàöèåíòàì ñ ÊÈÍÊ ïðîèçâîäèëàñü òðàíñïëàíòàöèÿ ïðåäøåñòâåííèêîâ ÝÊ â ñî÷åòàíèè ñ ââåäåíèåì ñîñóäèñòûõ ôàêòîðîâ ðîñòà. Ïîëó÷åí ñòîéêèé ýôôåêò ñïóñòÿ 6 ìåñÿöåâ ñ ìîìåíòà òðàíñïëàíòàöèè. Àâòîðû òàêæå óêàçûâàþò íà áåçîïàñíîñòü è ýôôåêòèâíîñòü äàííîé ìåòîäèêè [68, 69]. Àíàëîãè÷íîå ïî ìåòîäèêå èññëåäîâàíèå ïðîâåäåíî ãðóïïîé ïîä ðóêîâîäñòâîì Ê. Esato (2002). Èìè ïðîâåäåíà òðàíñïëàíòàöèÿ ÌÍÊ, âûäåëåííûõ èç êîñòíîãî ìîçãà 8 áîëüíûõ ñ õðîíè÷åñêèìè îáñòðóêòèâíûìè çàáîëåâàíèÿìè àðòåðèé íèæíèõ êîíå÷íîñòåé, îñëîæíåííûõ îáðàçîâàíèåì òðîôè÷åñêèõ ÿçâ [76].  ñðîêè äî 6 ìåñÿöåâ îò íà÷àëà òåðàïèè íàðàâíå ñ êëèíè÷åñêèì óëó÷øåíèåì è èñ÷åçíîâåíèåì áîëüøèíñòâà ñèìïòîìîâ îòìå÷åíî çàæèâëåíèå ÿçâ. Ð. Huang et al. (2004) ïðåäëîæèëè äðóãîé ïîäõîä ê àóòîëîãè÷íîé òðàíñïëàíòàöèè ÌÍÊ, ìîáèëèçîâàííûõ â ïåðèôåðè÷åñêóþ êðîâü ïîñðåäñòâîì G-CSF [77].  èññëåäîâàíèè ïðèíÿëè ó÷àñòèå 5 ÷åëîâåê, ñòðàäàþùèõ îáëèòåðèðóþùèì àòåðîñêëåðîçîì íèæíèõ êîíå÷íîñòåé III è IV ñòåïåíè. Âñå ïàöèåíòû èìåëè òðîôè÷åñêèå íàðóøåíèÿ â âèäå ÿçâ èëè ãàíãðåíû. Ýòèì ïàöèåíòàì â òå÷åíèå 5 äíåé ïîäêîæíî ââîäèëè G-CSF â äîçå 600 ì/ñóò [78]. Äëÿ ñíèæåíèÿ ïîòåíöèàëüíîãî ðèñêà àðòåðèàëüíîãî òðîìáîçà íà ôîíå ââåäåíèÿ G-CSF ïàöèåíòàì ââîäèëè ãåïàðèí â äîçå 10000 ÅÄ/ñóò. Ñòèìóëÿöèÿ G-CSF ïîçâîëèëà óâåëè÷èòü ñîäåðæàíèå CD34+ êëåòîê â ïåðèôåðè÷åñêîé êðîâè â 100 ðàç. Ïîñëå ñòèìóëÿöèè èç ïåðèôåðè÷åñêîé êðîâè ïàöèåíòîâ áûëà ïîëó÷åíà ñóñïåíçèÿ 300 ìë, ñîäåðæàùàÿ ôðàêöèþ ÌÍÊ, îáîãàùåííóþ CD34+. Ìåòîäèêà ââåäåíèÿ ÌÍÊ àíàëîãè÷íà îïèñàííîé ðàíåå. ×åðåç 3 ìåñÿöà íàáëþäåíèé îñíîâíûå êëèíè÷åñêèå ñèìïòîìû çíà÷èòåëüíî óëó÷øèëèñü áîëåå ÷åì ó ïîëîâèíû áîëüíûõ. Ïðè àíãèîãðàôèè îòìå÷àëîñü ñóùåñòâåííîå óëó÷øåíèå êîëëàòåðàëüíîãî êðîâîòîêà. N. Van Royen et al. (2003) áûëî ïðîâåäåíî ïèëîòíîå èññëåäîâàíèå, êîòîðîå çàêëþ÷àëîñü â ïðîâåäåíèè ìîíîòåðàïèè G-CSF ó ïàöèåíòîâ ñ îáëèòåðèðóþùèìè çàáîëåâàíèÿìè àðòåðèé íèæíèõ êîíå÷íîñòåé. Áûëè ïîëó÷åíû õîðîøèå ðåçóëüòàòû, äàþùèå ìåñòî äàííîìó ìåòîäó ëå÷åíèÿ ñðåäè äðóãèõ ìåòîäîâ íåïðÿìîé ðåâàñêóëÿðèçàöèè [79]. Âñå èññëåäîâàíèÿ, èçó÷àþùèå âëèÿíèå òðàíñïëàíòàöèè ïðîãåíèòîðíûõ ñîñóäèñòûõ êëåòîê íà íåîàíãèîãåíåç ïðè ÊÈÍÊ, òàê èëè èíà÷å áàçèðóþòñÿ íà ââåäåíèè ÌÍÊ ÊÌ áîëüøåé èëè ìåíüøåé ñòåïåíè «÷èñòîòû». Ñïîñîáû äîñòàâêè â îñíîâíîì ïðåäñòàâëåíû âíóòðèìûøå÷íûì è âíóòðèñîñóäèñòûì Êëåòî÷íàÿ òðàíñïëàíòîëîãèÿ è òêàíåâàÿ èíæåíåðèÿ Òîì II, ¹ 3, 2007 ââåäåíèåì. Ðàçðàáîòêà ñïîñîáîâ èäåíòèôèêàöèè ÏÝ è ÖÝÊ ïîçâîëèëà ðÿäó èññëåäîâàòåëåé ïðîâåñòè òðàíñïëàíòàöèþ òêàíåñïåöèôè÷íûõ êëåòîê [33, 35, 63]. Áîëüøèíñòâî èññëåäîâàíèé óêàçûâàþò íà ñòîéêèé ïîëîæèòåëüíûé ýôôåêò ïîñëå àóòîëîãè÷íîé òðàíñïëàíòàöèè ÑÊ áîëüíûì ñ ÊÈÍÊ â ñðîêè äî 6-8 ìåñÿöåâ.  2006 ãîäó ó÷åíûìè èç ßïîíèè çàêîí÷åíî ïèëîòíîå èññëåäîâàíèå ïî îöåíêå îòäàëåííûõ ðåçóëüòàòîâ òðàíñïëàíòàöèè ÌÍÊ áîëüíûì ñ îáëèòåðèðóþùèì òðîìáàíãèèòîì [80]. Èç 8 ïàöèåíòîâ, âîøåäøèõ â èññëåäîâàíèå, òðîå îòìå÷àëè íåïðåêðàùàþùèåñÿ áîëè â êîíå÷íîñòè, êðîìå òîãî, ó âñåõ ïàöèåíòîâ èìåëî ìåñòî ÿçâåííîå ïîðàæåíèå êîíå÷íîñòè. ×åðåç 4 íåäåëè îòìå÷åíî óëó÷øåíèå êëèíè÷åñêîãî ñòàòóñà ó âñåõ ïàöèåíòîâ. Ïîëíîå çàæèâëåíèå ÿçâ ïðîèçîøëî ó 7 èç 8 ïàöèåíòîâ. Âîññòàíîâëåíèå êðîâîñíàáæåíèÿ â èøåìèçèðîâàííûõ òêàíÿõ íèæíèõ êîíå÷íîñòåé çàâèñèò îò áàëàíñà ìåæäó îáðàçîâàíèåì êðîâåíîñíûõ è ëèìôàòè÷åñêèõ ñîñóäîâ. Äèñôóíêöèÿ ëèìôàòè÷åñêîé ñèñòåìû ïðèâîäèò ê îòåêó, êîòîðûé ÿâëÿåòñÿ ïðè÷èíîé äëèòåëüíî íåçàæèâàþùèõ ÿçâ. Ââåäåíèå VEGF-C óñêîðÿåò âîññòàíîâëåíèå ôóíêöèè èøåìèçèðîâàííîé íèæíåé êîíå÷íîñòè ïîñðåäñòâîì óâåëè÷åíèÿ ñêîðîñòè îáðàçîâàíèÿ ëèìôàòè÷åñêèõ è êðîâåíîñíûõ ìèêðîñîñóäîâ è óìåíüøåíèåì îòåêà [81-83]. Íåòðîìáîãåííûå ñîñóäèñòûå ïðîòåçû Íåäàâíî â õèðóðãè÷åñêîì ëå÷åíèè àòåðîñêëåðîçà êîðîíàðíûõ àðòåðèé áûëè ïðèìåíåíû àóòîëîãè÷íûå ñîñóäèñòûå ïðîòåçû. Êàê àëüòåðíàòèâà ýòîìó, áèîäåãðàäèðóþùàÿ ìàòðèöà îáåñïå÷èëà àäåêâàòíóþ çàìåíó äëÿ ñîñóäîâ áîëüøîãî êàëèáðà. Îäíàêî îñëîæíÿþùèì ôàêòîðîì ÿâëÿåòñÿ îáðàçîâàíèå òðîìáîâ íà ïîâåðõíîñòè ìàòðèöû èç-çà êîíòàêòà ñ êðîâüþ. Îäèí èç ñïîñîáîâ èñïîëüçîâàíèÿ ýíäîòåëèàëüíûõ ïðîãåíèòîðíûõ êëåòîê ýòî îáðàçîâàíèå íåòðîìáîãåííûõ ñîñóäèñòûõ êëåòîê, êîòîðûå áû ïîêðûâàëè ïîâåðõíîñòü ñîñóäèñòîãî ïðîòåçà.  îäíîì èç èññëåäîâàíèé êëåòêè ÊÌ áûëè âíåäðåíû â ñèíòåòè÷åñêèé ïðîòåç ïåðåä ïåðåñàäêîé åãî âíóòðü àîðòû ñîáàêè, ÷òî ïðèâåëî ê ôîðìèðîâàíèþ íåòðîìáîãåííîé ýíäîòåëèçèðîâàííîé ïîâåðõíîñòè [95]. Àóòîëîãè÷íûå ÖÝÊ òàêæå äèôôåðåíöèðîâàëèñü in vitro äî çðåëûõ ýíäîòåëèîöèòîâ è ïîñëåäîâàòåëüíî «çàñåëÿëè» ïðîòåçû â ñîííûõ àðòåðèÿõ. Ýòî ïðèâåëî ê îáðàçîâàíèþ íåòðîìáîãåííûõ ôóíêöèîíàëüíî ïîëíîöåííûõ ñîñóäîâ, êîòîðûå îñòàâàëèñü èíòàêòíûìè íà ïðîòÿæåíèè 120 äíåé, â ïðîòèâîïîëîæíîñòü òîìó, ÷òî â ñîñóäèñòûõ ïðîòåçàõ áåç ýíäîòåëèàëüíîé âûñòèëêè ôîðìèðîâàëèñü òðîìáû. Ñîêðàòèìîñòü è êèñëîðîä-çàâèñèìàÿ ðåëàêñàöèÿ, èçìåðÿåìûå ÷åðåç 120 äíåé in vivo, áûëè ñõîäíûìè ñ òàêîâûìè â íîðìàëüíûõ àðòåðèÿõ. Ýòè äàííûå ñâèäåòåëüñòâóþò î òîì, ÷òî ïðåäâàðèòåëüíàÿ âûñòèëêà ñîñóäèñòûõ ïðîòåçîâ ýíäîòåëèåì èç âûäåëåííûõ ÏÝ è ÖÝÊ îáëåã÷àåò ðåìîäåëèðîâàíèå in vivo, ñïîñîáñòâóåò ôîðìèðîâàíèþ íåòðîìáîãåííûõ ýíäîòåëèçèðîâàííûõ ïîâåðõíîñòåé. Êëèíè÷åñêèå îñëîæíåíèÿ, ñâÿçàííûå ñ ëå÷åíèåì ñòâîëîâûìè êëåòêàìè Âíóòðèâåííîå ââåäåíèå ïðîàíãèîãåííûõ ÏÝ è ÖÝÊ è ÃÑÊ ìîæåò èìåòü íåáëàãîïðèÿòíûå ýôôåêòû. Ðÿä èññëåäîâàíèé ïîêàçàëè, ÷òî ó ìûøåé ñ ãèïåðõîëåñòåðèíåìèåé, VEGF-A è èììóíîêîìïåòåíòíûå êëåòêè ìîãóò óñêîðÿòü îáðàçîâàíèå àòåðîìàòîçíûõ áëÿøåê ïîñðåäñòâîì ìîáèëèçàöèè ÏÝ è ìîíîöèòîâ [96, 97]. Èçáåæàòü ýòèõ ïîòåíöèàëüíûõ îñëîæíåíèé ìîæíî ïóòåì ââåäåíèÿ ÏÝ, ÖÝÊ, ÃÑÊ è ãåìàòîïîýòè÷åñêèõ ïðîãåíèòîðíûõ êëåòîê íåïîñðåäñòâåííî â ìåñòà ïîâðåæäåíèÿ òêàíè, èçáåãàÿ íåæåëàòåëüíîãî çàñåëåíèÿ êëåòêàìè äðóãèõ ìåñò. Îáçîðû ×òî ÿâëÿåòñÿ áîëåå ïðåäïî÷òèòåëüíûì âíóòðèñîñóäèñòîå èëè âíóòðèìûøå÷íîå ââåäåíèå ñòâîëîâûõ êëåòîê? Ïóòü ââåäåíèÿ ÑÊ îêàçûâàåò âàæíîå âëèÿíèå íà âàñêóëÿðèçàöèþ òêàíåé. Ýêñïðåññèÿ ìîëåêóë ìàòðèêñà è àäãåçèÿ ê ïîâðåæäåííûìè òêàíÿìè îáåñïå÷èâàþò çàõâàò ðåöåïòîðàìè ìîáèëèçîâàííûõ ÖÝÊ, ÃÑÊ è ãåìîïîýòè÷åñêèõ ïðîãåíèòîðíûõ êëåòîê ïðè èõ âíóòðèñîñóäèñòîì ââåäåíèè.  íàñòîÿùåå âðåìÿ óñòàíîâëåíî, ÷òî ïîñëå ïîâðåæäåíèÿ ñîñóäèñòîé ñòåíêè ÏÝ ñïîíòàííî ïîñòóïàþò â êðîâîòîê [98-100]. Âîçíèêàåò âîïðîñ, ïî÷åìó ìîáèëèçàöèÿ ýòèõ êëåòîê àâòîìàòè÷åñêè íå âîññòàíàâëèâàåò ðåâàñêóëÿðèçàöèþ òêàíåé è ïî÷åìó íåîáõîäèìî ââåäåíèå ýòèõ êëåòîê èíúåêöèîííûì ìåòîäîì? Ýòî îáúÿñíÿåòñÿ òåì, ÷òî ÏÝ íå äîñòèãàþò òîé ñòåïåíè äèôôåðåíöèðîâêè, êîòîðàÿ îáåñïå÷èâàåò èõ âíåäðåíèå â èøåìèçèðîâàííóþ òêàíü. Àëüòåðíàòèâíûì îáúÿñíåíèåì ÿâëÿåòñÿ òî, ÷òî íåäîñòàòî÷íîñòü êðîâîòîêà â èøåìèçèðîâàííîé òêàíè ìåøàåò ýòèì êëåòêàì ðàñïîçíàòü ïîâðåæäåííûå ñîñóäû. Íåïîñðåäñòâåííîå ââåäåíèå ÏÝ â çîíó ïîâðåæäåíèÿ ïîçâîëÿåò îáîéòè ýòè ïðåïÿòñòâèÿ. ËÈÒÅÐÀÒÓÐÀ: 1. Ñàâåëüåâ Â.Ñ., Êîøêèí Â.Ì. Êðèòè÷åñêàÿ èøåìèÿ íèæíèõ êîíå÷íî-ñòåé. Ì.: Ìåäèöèíà; 1997. 2. Second European Consensus Document on chronic critical leg ischemia. Circ. 1999; 84(IV): 1-26. 3. Dormandly J.A., Rotherford R.B. Management of peripheral arterial disease. TASC Group. Trans Atlantic Inter-Society Consensus. J. Vasc. Surg. 2000; 31: 1-296. 4. Ñìîëÿíèíîâ À.Á. 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