First in Man: Sternal Reconstruction with Autologous Stem Cells Zain Khalpey .1' Katherine M.

First in Man: Sternal Reconstruction with Autologous Stem Cells Zain Khalpey .1' Katherine M. Marsh,* Alice Femg,* lrbaz Bin Riazit Courtney Hemphill,* Kitsic Johnson,* Isabel Ohs a4 and Mark Friedman§ Acknowledgment The authors acknowledge IntelliCell BioSciences and Dr. Steven Victor, MD for implementation of the SVF isolation protocol using ultrasonic cavitation. The authors thank Synthes who helped 3D print the diseased sternum for preoperative surgical planning. EFTA01193379 ASAIOlournal 2015 Last eepu-:, First in Man: Sternal Reconstruction with Autologous Stem Cells ZAN KHALPEV,• KATHERINE M. MARCH,* ALICE IRBAE 61. RW,t C(%RTNEY I IMPHILL,* KITSIE JOHNSON,' ISABEL OLIVA,$ AND MARK filiE0wAs§ Sternal nonunion is associated with high morbidity and treated using rigid plate and screw fixation. This is the first reported example of successful sternal reconstruction using adipose- derived stromal vascular fraction (SW) stem cells in addition to traditional techniques. Mesendwrnal stem cells, one com- ponent of the SW, play an important role in bone healing and were therefore used to promote remedial processes in a patient with sternal nonunion. A 3D printed model of the patient's ster- num was used for preoperative planning of the plating. Intra- operatively, SVF was isolated using ultrasonic cavitation and previously planned sternal plating was completed. A total of 300 million cells were delivered via both local injection and intravenously before chest closure. The patient's pain dramati- cally decreased, commensurate with healed areas of nonunion by 3 months and maintained at 6 months postoperatively, supported by three-dimensional computed tomography imag- ing. Utilizing autologous stem cells from the SVF in conjunc- tion with existing plating techniques may provide an optimal platform to stabilize the sternum and promote bone healing, although additional study is recommended. ASAIO Journal 2015; 61:e31-e32. Key Mnrds: sternal reconstruction, autologous stem cells, human adipose-derived stem cells, hADSCs, adipose-derived stromal vascular stein cells, MC Sternal nonunion, although rare, is associated with high mor- bidity) Various fixation techniques have been described with the ultimate goal of rigid fixation and bony union to promote bone healing) Natural bone healing involves many pincemes includ- ing stern cell involvement. Research has highlighted the important role of mesenchsmal stem cells IMSCs) in bone repair, which has lead to the exploration of additional therapeutic options.' Emerg- ing treatments include the use of adipose-derhed stromal vascular fraction lsvn cells, which contain multi-potent CD3 I +, CD34+, CD-14+, C090., a)73+. and CO105+ cells characteristic of MSCs, in addition to exhibiting mesodermal capacity.' Stromal vascular fraction cells have been studied extensively in vitro over from the 'Division of Cardiothoracic Surgery, Department of Sur. b)ers: iDepartment of internal Medicine. 'Department of It-Ashok.% and §INvision of Cardiology, Department of Internal medicine, Flannel- University medical center, luoon, Arizona. Submitted for consideration August 2014: accepted tor publication in revised form December 2014. Disclosure The authors have no conflicts of interest ro report. Supported by the University of Arizona medical Center and College of medicine, Department of Surgery. li orrespondence Zain Khaipey, 1501 N. carnpbell Ave, fon 4.302A Box 245071 Tucson. AZ 85724.5071. Email: zkhalpeyesurgery. anion «du. Copyright O 2015 k the Anx-fican Society for Artificial Internal (Jegant DOI: 10.1097/MAT.0000000000000236 the past decade. Their potential as progenitor/stem cells has been shown to be equivalent to the properties of pluripotent stem cells or oven advantageous to using other populations of stern cells due to their low immunogenicityl These cells can be readily isolated via noninvasive lipoaspiration from subcutaneous fat at a much higher yield than other sources, and has since e, nerged as an alter- native tissue source for use in regenerative medicine. These ad-- pose-tissue SW cells, or adipose-derived stem cells (ASCs, have been used in studies that include cartilage and hone regeneration, wound healing, articular cartilage defaces, and tissue regeneration. Because SVF cells can be used without expansion and cell-culture treatment, the stem cells undergo minimal manipulation before clinical use. Though in vitro expansion also sham that human MSCs do not seem to undergo malignant transformation. SW cells are even more sale and efficacious due to the minimal manipu- lation! Other studies show further evidence that there are yan- ks components of crude SVF that act synergistically with ASCs, which may be non' clinically beneficial than ASCs alone.' Adi- pose-cierised stem cells are also more immurtosuppresshe than bone marrow-derised stern cells, another common source used in preclinical and clinical studies/ There are many current, ongoing clinical trials invoking the use of autologous adipose tissue SW cells for various disease etiologies including osteoarthritis, spinal cord injury, multiple sclerosis, and acute msdardial infarction!' Although there is always a possibility of side effects from the deliv- ery cistern cells, minimal side effects are expected from SVF MSCs compared with other cell types, because ,v6Cs have been shown to modulate 1-cell-mediated immunological responses.' Methods of delivery include both intravenous injection and local injection. both of which have been shown to cause cell homing to the sited ischemia or injury? Here. aye outline the first reported case of successful sternal reconstruction with autologous stem cells from the WE. Utiliz- ing this accessible heterogeneous mixture of cells in conjunc- tion with existing plating techniques may provide an optimal platform to stabilize the sternum and promote bone healing. Case Report A 65 sear old male presented with disabling pleuritic chest pain due to chronic sternal nonunion with bone loss after coro- nary artery bypass grafting. This began following an episode of severe coughing secondary to upper respiratory tract infection. Three-dimensional computed tomography of the chest (3D CT) showed a comminuted lower sternal fracture and nondisplared healing fractures of the left fifth and right fifth and sixth ribs. Although the wired upper portion of the sternum remained intact, the lower sternum had fractured in three places and distracted into four principal pieces greater than 5cm apart figure 1A). Amer medical therapy proved unsuccessful, a sternal reconstruction and unilateral pectoralis flap reconstruction was recommended. Given the extensive sternal nonunion, we constructed a preoped- tive 3D printed image of the patients sternum augmented with e31 Copyright American Society of Artificial Internal Organs Unauthorized reproduction of this article is prohibited. EFTA01193380 Figure 1. Three-Ornersgonal corr.outeci tomography image. Fracture sites and regions of sternal nonunion are indicated by arrows preoperatively (AL and healed fractures are indicated by avows at 3 months (B) and 9 months postoperatively (C)- biomaterials and mock-prepared the joints and the plating sys- tem (Synthes, DePuy, Ws) Chester, l'A). This was completed to both plan and practice the procedure in three dimensions before surgery. Although in vitro stem cell injection was not completed during the planning phase, after completion of the plating, we identified potential locations for local stem cell injection. Intraoperatively, we performed sternal plating with bone putty as planned preoperatively, and harvested autologous adipose- derived WE stem cells with ultrasonic cavitation unfelt'Cell Bio- sciences, New York, NY). A sterile section of the operating room (OR) was used for the WE isolation procedure, which included a centrifuge, flow atometer, sonicator probe, and the neces- sary accessories. Before the plating procedure, lipoaspirate was obtained via standard liposuction from the patients abdomen. The WE isolation procedure was immediately' implemented using the lipoaspirate and completed 1 hour later, by the time the surgeon had completed the sternal reconstruction. This allowed for prompt injection of the freshly isolated, autologous SVF cells: 100 million via localized injection and ?CO million eta intravenous injection. The SVF was a heterogeneous popula- tion of cells and extracellular matrix that can be used clinically without expansion.' and was mostly composed of CD34+ cells with approximately 88% cell viability. finally, a unilateral pec- loralis flap reconstruction was completed before closure. Serial 3D CT imaging demonstrated fracture healing and closure of areas of nonunion 3 and 6 months postoperatively compared with preoperative imaging figure 1B, C). Since sue gery, the patient has established regular follow up at our out- patient facility. His sternum is stabilized and he now reports minimal to no pain, with normal exercise tolerance. This case is the first reported example in man of successful sternal recon- struction with adipose-derived SVE Discussion Medial sternontomies are the gold standard for many car- diothoracic surgical procedures. Sternal nonunion occurs in approximately 0.5-3% of all patients with standard wire fixa- tion, with greater risk in patients who are on prolonged ven- tilation, female, older age, or overweight.. Treatment options have included repeat circumferential peristernal rem iring, steel banding, polymer tapes, and absorbable sutures. but currently rigid plate and screw fixation is most widely utilized.' Despite improvements in fixation technologies and alio- geneic bone matrices, there is no guarantee that healing will occur. As mentioned earlier, hunun AM(: transplantation has shown promise in current orthopedic-related clinical studies. including osteoarthritis and spinal cord injury.' ' In addition, the usefulness of ASCs in various mound and bone healing applications has been studied in multiple animal models with evidence that they promote the type of accelerated regenera- tion we have seen in our patient.' Due to the ability to eas- ily acquire both autologous stem cells ladipose-derived and stromal vascular progenitor cells? and native micromatrix from liposuction-derived adipose tissue in the operating roan, our method of SW isolation and application make this an attractive therapeutic option. The engraftment of the SVF and generation of stable bone highlights the importance of cell-matrix com- bination therapy options, rather than stem cell therapy alone. This has implications for cardiac and orthopedic regeneration. Acknowledgment The authors acknowledge IntelliCell RioSciences and Dr. Steven Vic- tor, MD for implementation of the SW isolation protocol using ultra- sonic cavitation. The authors thank synths,% who helped 3D print the diseased sternum for preoperative surgical planning. References 1. Chepla K1, Salgado Cl, Tang CI. Mardini S, Fvans 10<: late com- plications of chest wall reconstruction: Management of painful sternal nonunion. Semis Plait Sorg 25: 98-106, 2011. 2. Scrioga M. Viswanathan 5, Darinskas A, Slaby 0. Michalek 1: Same or not the same? Comparison of adipose tissue-derived versus bone 'narrow-derived mesenchymal gem and stromal cells. Stern ret7s 13ev 21: 2724-2752. 2012. 3. Khalpey L, lanardhanan R. Konhilas 1, Hemphill C: First in 111411: Admose-derned stromal vascular fraction cells may promote restorative cardiac function. Am/ .leer/ 127: ell-e12, 2014. 4. Translational Rictsciences. Safety and feasibility study of autologous stromal vascular fraction 'SW, cells for treatment of osteoarthri- tis. In: ClinicatTrials.gov :Internet]. National Lbrary of Medicine (US). June 2013. Available at httpsYclinicaltrialsgov/show/ WM1885832. Accessed October 19th, 2014. 3. Yagi H, Soto-Gutierrez A, Parekkadan 8, et al: Mesenchymal stem cells: Mechanisms of immunomodularicin and homing. Cell transplant 19: 667-679, 2010. 6. I lannoush El. Sail ZC. Flhassan lo, err 4: Impact of enhanced mobilization of bone marrow derived cells to site of injury. I Trauma 71: 283-9; discussion 289, 2011. 7. Demme O, .Moisan A, Dimastromageo I. et al: Intravenous admin- istration of 99mTc-I IMPAO.labeled human mesenchyrnal stem cells after stroke In vivo imaging and biodistribution. Cell Trantplani 18: 1349-1379, 2009. 8. Climble km, Bunnell BA. Chiu ES, GuiLak F: Concise review: Adipose-derived stromal vascular fraction cells and stern cells: Let's not get lost in translation. Stem cas 29: 749-754, 2011. Copyright © American Society of Artificial Internal Organs Unauthorized reproduction of this article is prohibited. EFTA01193381 ASAIO I O U R N A L EFTA01193382