BlueCross BlueShield of Tennessee Medical Policy Manual

Stem Cell Therapy for Peripheral Artery Disease


Peripheral arterial disease (PAD) is a common atherosclerotic syndrome associated with significant morbidity and mortality. Development of PAD is characterized by narrowing and occlusion of arterial vessels and eventual reduction in distal perfusion. Critical limb ischemia is the end stage of lower-extremity PAD in which severe obstruction of blood flow results in ischemic pain at rest, ulcers, and a significant risk for limb loss. The standard therapy for severe, limb-threatening ischemia is revascularization aiming to improve blood flow to the affected extremity. If revascularization fails or is not possible, amputation is often necessary.

A proposed treatment for critical limb ischemia due to peripheral arterial disease is stem cell therapy. The rationale of hematopoietic cell/bone marrow-cell therapy in PAD is to induce arteriogenesis by boosting the physiologic repair processes. This requires large numbers of functionally active autologous precursor cells and, subsequently, a large quantity of bone marrow or other source of stem cells. The concentrate of bone marrow aspirate contains a mix of cell types, including lymphocytoid cells, erythroblasts, monocytoid cells and granulocytes. Following isolation and concentration, the hematopoietic cell/bone marrow concentrate is administered either intra-arterially or through multiple injections into the muscle. 




The current literature on stem cells as a treatment for critical limb ischemia due to PAD consists primarily of phase 2 studies using various cell preparation methods and methods of administration. A meta-analysis of the trials with the lowest risk of bias has shown no significant benefit of stem cell therapy for overall survival, amputation-free survival, or amputation rates. Well-designed randomized controlled trials with a larger number of subjects and low risk of bias are needed to evaluate the health outcomes of these various procedures. More data on the safety and durability of these treatments are also needed. The evidence is insufficient to determine the effects of the technology on health outcomes.


BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2017). Stem cell therapy for peripheral arterial disease (8.01.55). Retrieved December 18, 2017 from BlueWeb. (18 articles and/or guidelines reviewed)

Franz, R., Shah, K., Pin, R., Hankins, T., Hartman, J., & Wright, M. (2015). Autologous bone marrow mononuclear cell implantation therapy is an effective limb salvage strategy for patients with severe peripheral arterial disease. Journal of Vascular Surgery, 62 (3), 673-680. Abstract retrieved February 26, 2016 from PubMed database.

Peeters Weem, S., Teraa, M., de Borst, G., Verhaar, M., & Moll, F. (2015). Bone marrow derived cell therapy in critical limb ischemia: a meta-analysis of randomized placebo controlled trials. European Journal of Vascular and Endovascular Surgery, 50 (6), 775-783. Abstract retrieved February 26, 2016 from PubMed database.

Qadura, M., Terenzi, D.C., Verma, S., Al-Omran, M., & Hess, D.A. (2017). Cell therapy for critical limb ischemia: an integrated review of pre-clinical and clinical studies. Stem Cells, 2017 Dec 11. Doi:10.1002/stem.2751. [Epub ahead of print]. Abstract retrieved December 18, 2017 from PubMed database.

Rigato, M., Monami, M., & Fadini, G.P. (2017). Autologous cell therapy for peripheral arterial disease: systematic review and meta-analysis of randomized, nonrandomized, and noncontrolled studies. Circulation Research, 120 (8), 1326-1340. Abstract retrieved December 18, 2017 from PubMed database.

U. S. Food and Drug Administration. (2002, October). Center for Devices and Radiological Health. Pre-market approval decisions K071934 (MarrowStim™). Retrieved January 20, 2017 from

U. S. Food and Drug Administration. (2010, December). Center for Devices and Radiological Health. Pre-market approval decisions K10334 (SmartPRep®). Retrieved July 14, 2011 from

Xie, B., Luo, H., Zhang, Y., Wang, Q., Zhou, C., & Xu, D. (2018). Autologous stem cell therapy in critical limb ischemia: a meta-analysis of randomized controlled trials. Stem Cells International, doi: 1155/2018/7528464. (Level 2 evidence)




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