cells

Review
Stem Cells and Angiogenesis: Implications and Limitations in
Enhancing Chronic Diabetic Foot Ulcer Healing
Vikrant Rai 1, * , Rebecca Moellmer 2 and Devendra K. Agrawal 1

1 Department of Translational Research, Western University of Health Sciences, Pomona, CA 91766, USA;
dagrawal@westernu.edu
2 College of Podiatric Medicine, Western University of Health Sciences, Pomona, CA 91766, USA;
rmoellmer@westernu.edu
* Correspondence: vrai@westernu.edu; Tel.: +1-909-469-7042

Abstract: Nonhealing diabetic foot ulcers (DFUs) are a continuing clinical issue despite the improved
treatment with wound debridement, off-loading the ulcer, medication, wound dressings, and pre-
venting infection by keeping the ulcer clean. Wound healing is associated with granulation tissue
formation and angiogenesis favoring the wound to enter the resolution phase of healing followed by
healing. However, chronic inflammation and reduced angiogenesis in a hyperglycemic environment
impair the normal healing cascade and result in chronically non-healing diabetic foot ulcers. Promot-
ing angiogenesis is associated with enhanced wound healing and using vascular endothelial growth
factors has been proven beneficial to promote neo-angiogenesis. However, still, nonhealing DFUs
persist with increased risks of amputation. Regenerative medicine is an evolving branch applicable
in wound healing with the use of stem cells to promote angiogenesis. Various studies have reported
promising results, but the associated limitations need in-depth research. This article focuses on
summarizing and critically reviewing the published literature since 2021 on the use of stem cells to
promote angiogenesis and enhance wound healing in chronic non-healing DFUs.

Citation: Rai, V.; Moellmer, R.;

Keywords: chronic inflammation; diabetic foot ulcers; neo-angiogenesis; stem cells; wound healing
Agrawal, D.K. Stem Cells and
Angiogenesis: Implications and
Limitations in Enhancing Chronic
Diabetic Foot Ulcer Healing. Cells
1. Introduction
2022, 11, 2287. https://doi.org/
10.3390/cells11152287 The diabetic foot ulcer (DFU) is a vascular complication of diabetes mellitus (DM)
affecting nearly 6.3% of the global population and a prevalence of 13% in the USA [1,2].
Academic Editor: Domenico Ribatti
Wound debridement, off-loading the ulcer, medication, wound dressings, and preventing
Received: 2 July 2022 infection by keeping the ulcer clean are the gold standard in the treatment of diabetic
Accepted: 22 July 2022 foot ulcers (DFU). Despite the advancement in methods of wound healing, chronic DFU
Published: 25 July 2022 remains a critical clinical problem associated with costly and prolonged treatment, risk
of amputation, and a high degree of morbidity and mortality. Diabetic vasculopathy,
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
decreased angiogenesis, ischemia, chronic inflammation, and the wound environment
published maps and institutional affil-
interfering with the effect of endogenous factors regulating the healing response render the
iations.
wound in a chronic inflammatory state without progressing to the resolution phase [3–6].
Wound healing comprises four phases including homeostasis/coagulation, inflammatory
cell recruitment, the proliferative phase, and the maturation phase [6,7]. Angiogenesis and
granulation tissue formation plays a critical role in wound healing by providing nutrition,
Copyright: © 2022 by the authors. oxygen, and matrix. Angiogenesis is increased in the early phase of healing while the
Licensee MDPI, Basel, Switzerland. density of blood vessels decreases with healing and scar formation. Granulation tissue acts
This article is an open access article as a matrix for proliferating vessels, fibroblast migration, and collagen formation. Impaired
distributed under the terms and granulation tissue formation and angiogenesis are distinctive features of non-healing
conditions of the Creative Commons DFUs [8,9].
Attribution (CC BY) license (https:// The process of angiogenesis is well-orchestrated involving interaction between cellular
creativecommons.org/licenses/by/ and molecular mediators including fibroblast growth factor (FGF), vascular endothelial
4.0/).

Cells 2022, 11, 2287. https://doi.org/10.3390/cells11152287 https://www.mdpi.com/journal/cells

Cells 2022, 11, x FOR PEER REVIEW 2 of 14

Cells 2022, 11, 2287 2 of 14

The process of angiogenesis is well-orchestrated involving interaction between cel-
lular and molecular mediators including fibroblast growth factor (FGF), vascular endo-
thelial growth factor (VEGF), transforming growth factor (TGF)-β1, angiopoietin 2, and
growth factor
extracellular (VEGF),
matrix (ECM)transforming
environment. growth factor (TGF)-β1,
Additionally, angiopoietin
sprouty2, pigment 2, and extracellu-
epithelium-de-
lar matrix (ECM) environment. Additionally, sprouty2, pigment epithelium-derived
rived factor (PEDF), low-density lipoprotein receptor-related protein (LRP)6, thrombos- factor
(PEDF), low-density lipoprotein receptor-related protein (LRP)6, thrombospondin
pondin (TSP)1, chemokine (C-X-C motif) ligand (CXCL)10, chemokine (C-X-C motif) re- (TSP)1,
chemokine
ceptor (CXCR)3,(C-X-C motif) ligandgrowth
platelet-derived (CXCL)10,
factorchemokine (C-X-C
receptor beta motif) receptor
(PDGFR-β), (CXCR)3,
heparin-binding
EGF-like growth factor (HB-EGF), epidermal growth factor receptor (EGFR), growth
platelet-derived growth factor receptor beta (PDGFR-β), heparin-binding EGF-like sema-
factor (HB-EGF),
phorin3a, neuropilinepidermal growth
1, neural/glial factor(NG)2,
antigen receptor (EGFR),
laminin semaphorin3a,
8, laminin neuropilin
10, and regulator of1,
Gneural/glial antigen
protein signaling (NG)2,
(RGS)5 laminin
also regulate8, angiogenesis
laminin 10, and regulator
during wound ofhealing.
G proteinECMsignaling
intri-
(RGS)5 also regulate angiogenesis during wound healing. ECM intricately
cately regulates angiogenesis and vasculogenesis by regulating the expression of the ECM regulates an-
giogenesis and vasculogenesis by regulating the expression of the ECM
receptor, αvβ3, the integrin receptor for fibrin and fibronectin [9–12]. Cytokines secretedreceptor, αvβ3,
the integrin
from receptor
infiltrating for fibrinand
macrophages andfibroblasts
fibronectinsupport
[9–12]. Cytokines
ECM formationsecreted
andfrom infiltrating
angiogenesis.
macrophages and fibroblasts support ECM formation and angiogenesis. The expression of
The expression of integrin receptors mobilizes the sprouting vessels to penetrate fibrin
integrin receptors mobilizes the sprouting vessels to penetrate fibrin and fibronectin-rich
and fibronectin-rich tissue aiding in wound healing. However, when granulation tissue
tissue aiding in wound healing. However, when granulation tissue and ECM are replaced
and ECM are replaced by collagen-rich tissues, vessel formation regresses and degener-
by collagen-rich tissues, vessel formation regresses and degenerates through apoptosis
ates through apoptosis involving anti-angiogenic factors [11] (Figure 1).
involving anti-angiogenic factors [11] (Figure 1).

Figure 1. Angiogenesis in wound healing. Vascular endothelial growth factor (VEGF) secreted from
Figure 1. Angiogenesis in wound healing. Vascular endothelial growth factor (VEGF) secreted from
fibroblasts in the wound environment activates endothelial cells (ECs) leading to increased secretion of
fibroblasts in the wound environment activates endothelial cells (ECs) leading to increased secretion
of proteolyticproteins.
proteolytic proteins.Increased
Increased matrix
matrixmetalloproteinases
metalloproteinases (MMPs)
(MMPs) from macrophages
from macrophages andand
proteolytic
prote-
enzymes
olytic facilitate
enzymes the disruption
facilitate of theofbasement
the disruption the basementmembrane, migration
membrane, of ECs,
migration and sprouting
of ECs, of the
and sprouting
ofnew
the vessels into the
new vessels wound.
into This process
the wound. is facilitated
This process by increased
is facilitated expression
by increased of adhesion
expression proteins
of adhesion
proteins
(VCAM-1) (VCAM-1) and integrin
and integrin receptors
receptors (αvβ 1,(αvβ1,
αvβ 3,αvβ and3,αvβ
and 5)
αvβ
and5) mediators
and mediators of angiogenesis
of angiogenesis such
such as platelet-derived
as platelet-derived growth
growth factor
factor (PDGF),
(PDGF), epidermal
epidermal growthgrowth
factorfactor (EGF),
(EGF), fibroblasts
fibroblasts growth
growth factor
factor
(FGF),(FGF), transforming
transforming growth growth
factor factor
(TGF)-α (TGF)-α
and β,and β, prostaglandin
prostaglandin E2 (PGE2),
E2 (PGE2), angiotensin
angiotensin (Ang)-1,
(Ang)-1, interleukin (IL)-8, and tumor necrosis factor (TNF)- α. Increased
interleukin (IL)-8, and tumor necrosis factor (TNF)- α. Increased recruitment of vascular recruitment of vascular
smooth
smooth muscle cells (VSMCs) and pericytes facilitate neo-angiogenesis and vasculogenesis. Once
muscle cells (VSMCs) and pericytes facilitate neo-angiogenesis and vasculogenesis. Once vessels
vessels are formed and wound healing enters the later phase of healing angiogenesis is suppressed
are formed and wound healing enters the later phase of healing angiogenesis is suppressed by the
by the inhibitory form of TGF-β and increased secretion of endostatin (collagen XVIII).
inhibitory form of TGF-β and increased secretion of endostatin (collagen XVIII).
Cells 2022, 11, 2287 3 of 14

Therapeutic strategies involving growth factors (PDGF, EGF, FGF, and VEGF), non-
growth factor proteins (insulin, erythropoietin, stromal-cell derived factor-1, spidroin, and
thymosin beta 4), peptides (anti-microbial peptides, cathelicidins, LL-37 derivatives, and
vasoactive intestinal peptide), blood-derived factors (PDGF-BB, TGF-β1, FGF-2, VEGF-A,
EGF, and platelet factor-4), microRNAs, drugs and small molecules (adenosine triphos-
phate, statins, deferoxamine, natural compounds, and hyaluronan), nanomaterials in the
scaffold, and stem cells (adipose-derived stem cells, bone marrow-derived mesenchymal
stem cells, induced pluripotent stem cells, and placenta-derived mesenchymal stem cells)
have been discussed to enhance angiogenesis and wound healing [13,14]. Becaplermin,
a recombinant platelet-derived growth factor, is an FDA-approved drug to treat a neuro-
pathic ulcer in diabetes, systemic bioavailability is a limitation [15]. Thus, exploring new
treatment strategies is warranted for the treatment of ischemic DFUs. Using stem cells
for wound healing is another promising approach. Multiple articles in the literature have
reviewed the mechanism and the role of stem cells in enhancing wound healing [16–23].
Hence, this review focuses on the role of stem cells in promoting angiogenesis to enhance
wound healing.

2. Angiogenesis and Wound Healing

The process of angiogenesis is well regulated by angiogenic (TGF-β, TNF-α, VEGF,
PDGF, FGF, angiogenin, and angiopoietin-1) and anti-angiogenic (angiostatin, TIMP-2,
TSP-1, endostatin, sprouty 2, PEDF, PF-4, IFNα/β) factors [8,12,24] involving oxidative
stress (HIF-1α), inflammation, and Sonic Hedgehog (Shh) signaling. Reduction of angio-
genesis in the last phase of wound healing is essential for proper wound healing without
scarring and selective reduction of angiogenesis and inflammation has been suggested for
proper wound healing [12]. This suggests that increased angiogenesis plays a critical role
in normal wound healing during the early phase, but attenuation of angiogenesis is needed
for proper healing. However, this dynamic regulation of angiogenesis may alter during
diabetes due to changes in the expression levels of pro-and anti-angiogenesis proteins
(Figure 2), however, the available literature is not conclusive [25]. The inconsistencies be-
tween the results of the expression of pro-and anti-angiogenic factors may be due to loss of
tissue, presence of necrosis and gangrene, the differential response of fibroblasts to hypoxia,
different levels of inflammation, tissue fibrosis, vascular thrombosis, arteriolar sclerosis,
differential expression of these mediators in different cells in healthy versus wound tissues
and healthy versus diabetic tissue as well as different levels of hyperglycemia. Another
issue may be a differential expression between different types of diabetic ulcers. Difficulties
in translating the lab findings to therapy in clinics to improve angiogenesis and wound
healing are also due to the differential expression of these mediators in human versus
murine models [25]. Temporary hypoxia is needed for angiogenesis as increased expression
of HIF-1α dimerizes and activates hypoxia response elements causing increased expression
of VEGF, but the presence of hyperglycemia affects the stability and activation of HIF-1α
and attenuates angiogenesis through suppression of PDGF, VEGF, and TGF-β [26].
Cells 2022, 11, x FOR PEER REVIEW 4 of 14
Cells 2022, 11, 2287 4 of 14

Figure 2. Change in the expression levels of pro-and anti-angiogenic factors in chronic nonhealing
Figure 2. Change in the expression levels of pro-and anti-angiogenic factors in chronic nonhealing diabetes foot ulcers. Normal an-
giogenesis occurs with increaseddiabetes foot
expression ofulcers. Normal and
proangiogenic angiogenesis
decreasedoccurs with of
expression increased expression
antiangiogenic of proangiogenic
mediators. and
The expression
decreased expression of antiangiogenic mediators. The expression of proangiogenic factors
of proangiogenic factors decreases while antiangiogenic mediators increase in nonhealing diabetic foot ulcers. Vascular endothelial decreases
growth factor receptor (VEGFR)-2, while antiangiogenic factor
hypoxia-inducible mediators increase
1-alpha in nonhealing
(HIF-1α), diabetic foot
vascular endothelial ulcers.
growth Vascular
factor endothelial
(VEGF)-A, stromal
cell-derived factor (SDF)-1α, placental
growth growth
factor factor (PLGF)—a
receptor member
(VEGFR)-2, of the VEGF family,
hypoxia-inducible factor fibroblast growth factor
1-alpha (HIF-1α), (FGF),
vascular platelet-
endothelial
derived growth factor (PDGF), growth
platelet-derived growth factor
factor (VEGF)-A, receptor
stromal (PDGFR)-β,
cell-derived tumor necrosis
factor (SDF)-1α, factor
placental (TNF)-α,
growth transforming
factor (PLGF)—a
growth factor (TGF)-β, pigment epithelium-derived factor (PEDF), Krüppel binding protein (KBP)-1, thrombospondin (TSP)-1,
member of the VEGF family, fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), plate-
let factor (PF)-4, and tissue inhibitors of matrix metalloproteinases (TIMPs). The continuous line shows the expression
platelet-derived growth factor receptor (PDGFR)-β, tumor necrosis factor (TNF)-α, transforming levels during
normal wound healing while the dotted line and arrows represent the shift in expression levels.
growth factor (TGF)-β, pigment epithelium-derived factor (PEDF), Krüppel binding protein (KBP)-1,
thrombospondin (TSP)-1, platelet factor (PF)-4, and tissue inhibitors of matrix metalloproteinases
3. Stem Cells and Angiogenesis in DFUs
(TIMPs). The continuous line shows the expression levels during normal wound healing while the
dottedAngiogenic therapy
line and arrows using
represent thestem cells
shift in to enhance
expression levels.healing in refractory wounds has
shown promising therapeutic efficacy. Stem cells migrate to the site of the wound, differ-
3. Stem Cells
entiate, and Angiogenesis
proliferate, in DFUstissue formation, collagen deposition, and angi-
promote granulation
ogenesis, and ameliorate
Angiogenic neuro-ischemia
therapy using stem cells to and inflammation
enhance healingthereby enhancing
in refractory wounds woundhas
healing.promising
shown Angiogenesis is promoted
therapeutic efficacy.by increasing
Stem cells the secretion
migrate to theofsite
angiogenic factorsdif-
of the wound, in-
cluding VEGF
ferentiate, and Von
proliferate, Willebrand
promote factor tissue
granulation and endothelial cell recruitment
formation, collagen deposition, through
and
TNF- α. Mesenchymal
angiogenesis, stem cells
and ameliorate (MSCs) have
neuro-ischemia andbeen used to promote
inflammation thereby angiogenesis
enhancing wound in pre-
healing. Angiogenesis
clinical and is promoted
clinical studies [16,18,27]. byParacrine
increasing the secretion
signaling and theofcapability
angiogenic of factors
stem cells in-
cluding VEGF and Von Willebrand factor and endothelial cell recruitment
to differentiate into specialized cells including fibroblasts, vascular endothelial cells, and through TNF- α.
Mesenchymal
epithelial cells stem cells (MSCs)
contribute have been
to the efficacy usedcells
of stem to promote angiogenesis
in stimulating in pre-clinical
angiogenesis, neovas-
and clinical studies
cularization, [16,18,27]. Paracrine
and re-epithelialization. signaling
Stem andthe
cells heal thewound
capability of stem cells
by providing to differ-
a favorable
entiate into specialized
environment cellscytokines,
by secreting including fibroblasts,
chemokines, vascular endothelial
and growth factorscells, and epithelial
necessary to pro-
cells
ducecontribute to the efficacy
an extracellular matrix andof stem cells in stimulating
promoting angiogenesis,
neo-angiogenesis. Thus, neovascularization,
stem cells alter the
and
woundre-epithelialization.
microenvironment Stem cells heal
favorable the wound
for healing and by providing
promote tissuea regeneration
favorable environ- at the
ment by secreting cytokines, chemokines, and growth factors
wound site. Administration of stem cells is associated with the advantage of necessary toangiogenesis
produce an
extracellular matrix andinflammation,
promotion, attenuated promoting neo-angiogenesis.
and enhanced wound Thus,healing
stem cells alter
but is alsothe wound
associated
microenvironment
with side effects (Tablefavorable for healing
1). Further, and promote
stem cells have the tissue regeneration
advantage at the wound
of administering them
site.
alongAdministration of stem cells
with other treatments is associated
to exploit their rolewith
in the advantage
a better way for ofthe
angiogenesis
treatment promo-
of non-
tion, attenuated
healing inflammation, and enhanced wound healing but is also associated with
DFUs [16–18,28].
side effects (Table 1). Further, stem cells have the advantage of administering them along
with of
Table 1. Advantages and limitations other treatments
the stem to exploit
cells enhancing their role
healing in a better
in DFUs. wayshowed
Stem cells for theimproved
treatment of nonhealing
clinical efficacy in
DFUs
enhancing wound healing in DFUs [16–18,28].
by increased angiogenesis and re-epithelialization [17]. The common side effects associated with
stem cell therapy are whole body urticaria, diarrhea, oral ulceration, the elevation of serum creatinine level, number, and differenti-
ated potential decline with aging, nausea, and vomiting. Bone marrow-mesenchymal stem cells (BM-MSCs), umbilical cord blood-
Cells 2022, 11, 2287 5 of 14

Table 1. Advantages and limitations of the stem cells enhancing healing in DFUs. Stem cells showed
improved clinical efficacy in enhancing wound healing in DFUs by increased angiogenesis and
re-epithelialization [17]. The common side effects associated with stem cell therapy are whole body
urticaria, diarrhea, oral ulceration, the elevation of serum creatinine level, number, and differen-
tiated potential decline with aging, nausea, and vomiting. Bone marrow-mesenchymal stem cells
(BM-MSCs), umbilical cord blood-derived mesenchymal stem cells (UCB-MSCs), adipose-derived
mesenchymal stem cells (AMSCs), umbilical cord-derived mesenchymal stem cells (UC-MSCs),
placenta-derived mesenchymal stem cells (PMSCs), and human amniotic fluid-derived stem cells
(AF-MSCs), human gingiva-derived mesenchymal stem cells (GMSCs).

Source of Stem Cells Advantages

No immunologic restriction, does not stimulate alloreactivity,
escape lysis by T-cells and NK cells
BM-MSCs
Reduced formation of cytotoxic lymphocytes suppresses
T-cell-derived IFN-γ, intramuscular transplantation
Similar morphology and cell surface antigens, the potential of
differentiation into BM-MSCs
UCB-MSCs
Short doubling time, long viable time, anti-inflammatory
activity, intramuscular transplantation
AMSCs Characteristics like BM-MSCs, subcutaneous injection
Rich, safe, of short doubling time, and easy to collect
Fibroblastic morphology, typical immunophenotypic markers,
UC-MSCs
and multiple differentiation potential to BM-MSCs,
lower immunogenicity
A large number of cells can be isolated, better proliferation
capacity, intraperitoneal administration
PMSCs
The morphology, size, surface phenotype, and
immunosuppressive characteristics are like BM-MSCs
A large number of cells can be isolated from the small volume,
remain stable, have a high proliferative capacity, multilineage
AF-MSCs
differentiation potential, immunomodulatory activity
Lack of significant immunogenicity
Homogenous, not tumorigenic, easy to isolate, stable
phenotype, can be isolated without ethical problems, greater
GMSCs
capacity of proliferation and migration than AMSCs and
BM-MSCs without growth factors

Mesenchymal stem cells induce the mobilization of various angiogenesis factors in-
cluding SDF-1, VEGF, EGF, insulin-like growth factor-1 (IGF-1), angiopoietin (Ang)-1,
keratinocyte growth factor (KGF), MMP-9, macrophage inflammatory protein (MIP)-1α
and β and erythropoietin (EPO) to the wound bed stimulating recruitment, proliferation,
and differentiation of endothelial progenitor cells and thereby angiogenesis and wound
healing [16,27]. Among the MSCs, bone marrow-derived MSCs are more suitable to en-
hance healing in DFUs [17]. MSCs have been used in various studies and shown to have a
beneficial role in enhancing wound healing in DFUs. The molecular mechanism involved in
enhancing wound healing in DFUs using stem cells has been extensively reviewed [17,29].
Adult stem cells including bone marrow-derived mesenchymal stem cells (BM-MSC), pe-
ripheral blood-derived mesenchymal stem cells (PB-MSC), human umbilical cord-derived
mesenchymal stem cells (hUC-MSC), and adipose-derived mesenchymal stem cells (ADSC)
have been used in pre-clinical and clinical studies (Table 2). Additionally, enhanced wound
healing in a murine model of DFUs using human amniotic MSCs, the micronized amniotic
membrane containing human amniotic epithelial cells, human placental MSC, collagen
gels containing embryonic fetal liver MSCs, and collagen hydrogel scaffold to deliver
human fetal aortic MSCs has also been reported. Moreover, the use of embryonic stem cells,
induced pluripotent stem cells, and granulocyte-colony stimulating factors stimulating
bone marrow to mobilize endothelial progenitor cells at the wound site, have also been
documented and reviewed [19–23].
Cells 2022, 11, 2287 6 of 14

Table 2. Stem cells enhance angiogenesis and wound healing in DFUs. Neonatal porcine bone
marrow-derived mesenchymal stem cell (npBM-MSC), Adipose-derived mesenchymal stem cells
(ADSCs), human induced pluripotent stem cell-derived smooth muscle cells (hiPSCSMC), endothelial
differentiated adipose-derived stem cells (EC-ADSCs), human umbilical cord blood-derived CD34+
stem cells (UCB-CD34+ SC), bone marrow mononuclear cells (BMMNCs), endothelial progenitor cells,
human fetal aorta-derived CD133+ progenitor cells and their conditioned medium (CD133+ CCM),
human umbilical cord-derived MSCs (hucMSCs).

Stem Cell Strategy Parameters Checked Outcome

Xenotransplantation in Rate of wound closure and The wound closure rate was significantly
npBM-MSC [29] mice model of the promotion of improved on postoperative days 4 and 7
diabetic wound. neovascularization Promoted angiogenesis and lymphangiogenesis
ADSCs accelerate lymphatic endothelial cells
proliferation, migration, and lymphangiogenesis
Autologous Lymphangiogenesis ADSCs enhance VEGFR3-mediated
ADSCs [30]
transplantation in mice Wound healing lymphangiogenesis via METTL3-mediated
VEGF-C m6A modification to improve wound
healing in DFUs
hiPSC-SMC secretes increased concentration of
pro-angiogenic cytokines compared with
Xenotransplantation
murine ADMCs.
hiPSC-SMC embedded
To compare angiogenic hiPSC-SMC-containing collagen scaffolds
hiPSCSMC in 3D collagen scaffolds
factor secretion from accelerate diabetic wound healing
[31] were applied to diabetic,
ADMCs and hiPSCSMC hiPSC-SMC increases the number of total and
nude mice with splinted
M2 macrophages
back wounds
hiPSC-SMC increases angiogenesis via VEGF-A
and TGF-β1
Increased percentage of wound closure rates
with ADSCs and EC-ADSCs, and
Autologous Percentage of conditioned media
ADSCs [32]
transplantation in swine wound healing Increased angiogenesis with stem cell therapy
Significant decrease in inflammation with
stem cells
A significant decrease in mean wound surface
Xenotransplantation in a To evaluate the efficacy of
hUCB-CD34+SC area, increase in mean epidermal thickness,
rat model of stem cells in the healing
[33] blood vessel proliferation, and
diabetic wound locally. of wounds
collagen deposition
Autologous stem cells Accelerated wound healing and induced
Wound healing
EPCs-BMMNCs transplantation in expression of VEGF and bFGF promoting
and angiogenesis
mice topically angiogenesis
Stimulation of migration,
Xenotransplantation in angiogenesis-like network
Wound healing and
CD133+ CCM [34] mice model of formation and induction of Wnt expression
angiogenesis
diabetic wound Stimulate wound healing by
paracrine mechanisms
Human dermal ABCB5+
In mice
MSCs were transplanted
Accelerated perfusion recovery of ischemia
via intramuscular To evaluate the
ABCB5+MSCs Increased angiogenesis
injection in mice angiogenic potential of
[35] Clinical trial in human
ischemic limb and ABCB5+ MSCs
Reduction in wound surface area in therapy
topically in
refractory DFUs with topical application
human DFUs
hucMSCs ameliorated blood glucose and
hucMSCs were infused Repair of diabetic vascular protected vascular endothelium from diabetic
hucMSCs [36]
in diabetic rat endothelial cell damage damage through paracrine effect involving
MAPK/ERK signaling
Cells 2022, 11, 2287 7 of 14

Regarding the route of administration of stem cells to enhance wound healing, nonvas-
cular administration including intradermal, subcutaneous, and intramuscular injections are
the most used routes to enhance DFU wound healing. Additionally, local administration of
stem cells in a collagen-based hydrogel and systemic venous and arterial administration of
stem cells have also shown promising results [19,20]. Further, Yan et al. [37] reported that
both systemic and topical application of BM-MSCs have the potential of enhancing wound
healing and promoting neo-angiogenesis and vascularization but systemic administration is
associated with ameliorating hyperglycemia and improving blood perfusion of the ischemic
hindlimb of the diabetic rats with a positive wound distribution and trans-differentiation
to ECs.

4. Stem-Cell Derived Exosomes and Combinational Strategies to Enhance Diabetic

Wound Healing
Stem cells not only enhance angiogenesis but also attenuate the effects of diabetes and
protect endothelial cells [36]. Low cell retention and integration of stem cells are issues
of using hydrogels while administering stem cells to enhance wound healing in DFUs.
Shi et al. [38] reported that gelatin microspheres enhance the delivery and integration of
locally delivered adipose-derived stem cells from rats. The use of gelatin microspheres was
associated with M2 macrophage polarization, collagen deposition, angiogenesis, peripheral
nerve recovery, and hair follicle formation suggesting the efficacy of using microspheres
in enhancing healing in DFUs. In another study, Takahashi et al. [39] reported that topi-
cal application of hydrogels containing conditioned medium from hypoxically cultured
amnion-derived mesenchymal stem cells promotes wound healing in diabetic mice by
enhancing angiogenesis, accelerating epithelization, and suppressing inflammation. The
result of this study obviates the need for stem cell transplantation at the wound site though
future research is warranted.
Along with transplanting stem cells in gels or as nanoparticles, exosomes derived
from stem cells have also shown a beneficial effect in enhancing angiogenesis and wound
healing in DFUs. A study by Wang et al. reported the effectiveness of exosomes derived
from epidermal stem cells in improving diabetic wound healing [40]. The study reported
that compared to epidermal stem cells (ASC) alone, exosomes isolated from ASC (ASC-Ex)
showed better results in wound healing in db/db mice. Enhanced wound healing with
ASC-Ex was associated with decreased inflammation, augmented wound cell proliferation,
stimulating angiogenesis, and inducing M2 macrophage polarization. Heras et al. [41]
reported increased angiogenesis and human dermal fibroblasts proliferation and migration,
in vivo, with exosomes isolated from hair follicle-derived MSCs (HF-MSCs) and adipose
tissue-derived MSCs (AT-MSCs). Another study by Gondaliya et al. reported enhanced
collagen deposition, angiogenesis, and re-epithelialization in diabetic wounds with MSC-
derived exosomes loaded with miR-155 inhibitor in a mouse model [42]. Accelerated
wound healing was associated with keratinocyte migration, restoration of FGF-7 levels, and
decreased inflammation. The promotion of angiogenesis with accelerated diabetic wound
healing in diabetic mice was also reported with exosomes derived from human umbilical
cord mesenchymal stem cells via oxidative stress amelioration [43]. Decreased angiogenesis
or neovascularization in hyperglycemic state and old age may be due to senescent endothe-
lial cells (ECs) or decreased ECs proliferation. Xiao et al. [44] reported that mesenchymal
stem cell-derived small extracellular vesicles (MSC-sEV) mitigate oxidative stress-induced
ECs senescence and stimulate angiogenesis through miR-146a/Src. Increased angiogenesis
to enhance wound healing in diabetic rats by promoting HIF-1α-mediated angiogenesis in
the PI3K-AKT-mTOR dependent manner with extracellular vesicles derived from human
adipose-derived stem cells (hADSC-EVs) in association with accelerated wound healing
was reported by Liu et al. [45]. These findings suggest that mitigating EC senescence may
enhance angiogenesis and thus might be of therapeutic significance to enhance healing in
chronic non-healing DFUs. Further, stem cells have better therapeutic effects in combina-
Cells 2022, 11, 2287 8 of 14

tions with hydrogels, collagen matrix, and nanoparticles in comparison to stem cells alone
and pretreatment will enhance efficacy (Table 3).

Table 3. Combinational strategies with stem cells enhancing angiogenesis and wound healing in
DFUs: Exendin-4 (Ex-4) is a glucagon-like peptide-1 receptor agonist known to have many beneficial
effects on diabetes, human adipose tissue-derive stem cells (hADSCs), long noncoding RNA (Lnc),
bone marrow mesenchymal stem cells (BMSCs), self-assembled nano-peptide hydrogels with human
umbilical cord mesenchymal stem cell spheroids (hUC-MSCsp), acellular dermal matrix (ADM), extra
cellular matrix (ECM), hBM-MSCs/T/H/S embedded in an ECM scaffold (S) and preconditioned
with hypoxia (H) and the β-adrenergic receptor antagonist, timolol (T), Wharton’s jelly mesenchymal
stem cell (WJMSC), sodium ascorbyl phosphate (SAP), platelet rich plasma (PRP), human umbilical
cord mesenchymal stem cells (hUC-MSCs), 5-aminolevulinic acid photodynamic therapy (ALA-PDT),
EVs secreted by human umbilical cord mesenchymal stem cells (hucMSC-EVs), HOTAIR-MSC EVs-
extracellular vesicles (EVs) isolated from mesenchymal stem/stromal cells (MSCs) transfected to
overexpress long non-coding RNA HOX transcript antisense RNA (HOTAIR), endothelial cells (ECs),
catechol-functionalized hyaluronic acid (HA-CA) patch.

Treatment Combination/Strategy Assessing Parameters Study Outcome

Exosomes from hADSCs-derived exosomes were Angiogenesis and wound
Accelerate angiogenesis and wound
linc00511- injected into Sprague–Dawley healing
healing by suppressing
overexpressing (SD) rats along with human Underlying molecular
PAQR3-induced Twist1degradation
ADSCs [46] blood-derived EPC mechanism
BMSC-derived Exosomes were delivered via tail
Wound healing Induction of angiogenesis to promote
exosomal lncRNA vein injection in diabetic BALB/C
Angiogenesis diabetic cutaneous wound healing.
KLF3-AS1 [47] mice
Exosomes isolated from
PGZ-EX accelerates diabetic wound
supernatants of
Exosomes from healing via enhanced angiogenesis,
pioglitazone-treated BMSCs Wound healing
pioglitazone increased collagen deposition, ECM
(PGZ-Ex) were injected around Angiogenesis
pretreated MSCs [48] remodeling, and increased VEGF and
the wounds by multisite
CD31 expression
subcutaneous injection
hucMSC-EVs have regenerative and
protective effects on high
glucose-induced endothelial cells
hucMSC-EVs applied locally Angiogenesis involving the transfer of miR-17-5p
hucMSC-EVs [49]
to diabetic mice Wound healing to target
PTEN/AKT/HIF-1α/VEGF pathway
hucMSC-EVs promote angiogenesis
and accelerate wound healing
HOTAIR-MSC EVs were injected HOTAIR-MSC EVs promote
HOTAIR-MSC EVs Wound healing
around the wound in angiogenesis and wound healing in
[50] Angiogenesis
Sprague–Dawley rats diabetic (db/db) mice.
hADSCs were injected The combination of topical treatment
Wound size
Exendin-4 with intradermally around the wound of Ex-4 and injection of ADSCs has a
Wound histology
ADSCs [51] in db/db mice and Ex-4 was better effect therapeutically than
Angiogenesis
applied topically Ex-4 alone
Wound healing
Angiogenesis
hUC-MSCsp transplanted into Accelerated wound healing
Inflammation
hUC-MSCsp [52] wounded skin of mice model of Inhibited inflammation
Comparison between stem
diabetes Promotes angiogenesis
cells alone and in
combination
Cells 2022, 11, 2287 9 of 14

Table 3. Cont.

Treatment Combination/Strategy Assessing Parameters Study Outcome

The transplanted cells in the
ADSCs in the acellular dermal hypoxic-ADSCs/ADM membrane
Stem cell viability under
matrix under hypoxic and can survive longer at the chronic
ADSCs [53] hypoxic and
normoxic conditions applied over ulcer site and enhance angiogenesis,
normoxic conditions
DFU in a diabetic rat inhibits inflammation, and increase
ECM formation
MSC/T/H/S promoted wound
hBM-MSCs/T/H/S administered Wound healing
hBM-MSCs [54] re-epithelialization and angiogenesis
to porcine wound model Angiogenesis
and improved wound healing
WJMSC with PF-127 hydrogel
Promoted diabetic wound healing
and SAP were transplanted onto Wound healing
Decreased M1 and increased
WJMSC [55] excisional cutaneous wound bed Mitochondrial damage and
M2 macrophages
in type II diabetic oxidative stress
Increased angiogenesis
Sprague–Dawley rats
PRP+ADSCs compared to their
individual use are better for
ADSCs (isolated from rats) alone To compare the efficacy of
re-epithelialization, granulation
and ADSCs with PRP was ADSC alone vs. ADSC+ PRP
ADSCs [56] tissue formation, collagen deposition,
injected at the wound base and in wound healing
epidermal thickness, and
edges of diabetic Albino rats and angiogenesis
angiogenesis by modulating the
Notch pathway
ADSCs-PRP induced a higher wound
closure rate
ADSCs (isolated from rats)
Angiogenesis Increases the expression of VEGF,
ADSCs [57] combined with PRP were injected
Wound healing p-STAT3, and SDF-1
to wound in Sprague–Dawley rats
Promote ECs proliferation thereby
neovascularization
Combining ALA-PDT with
hUC-MSCs combined with hUC-MSCs possesses a significantly
To investigate the efficacy of
ALA-PDT- hUC-MSCs were enhanced therapeutic efficacy in
the combinational approach
injected intradermally to diabetic enhancing wound healing, promoting
hUC-MSCs [58] on wound closure,
C57BL/6J mice after exposing the angiogenesis, and attenuating
angiogenesis,
mice to ALA-PDT with 10% ALA inflammation and bacterial load
and inflammation
gel and 25 J/cm2 of PDT. suggesting its efficacy in healing
refractory wounds.
ADSCs combined with HA-CA
HA-CA + ADSCs enhanced wound
ADSCs were injected around the
Angiogenesis healing and angiogenesis
ADSCs [59] wound in diabetic C57BL/6 mice
Wound healing synergistically involving
and a patch was deposited on the
PI3K/AKT pathway.
wound
SDF-1α gene-activated scaffold
Human ADSCs with SDF-1α
overcomes the deficiencies associated
ADSCs [60] gene-activated scaffold were Pro-angiogenic properties
with diabetic ADSCs and restores
tested in vitro using HUVEC
pro-angiogenic features ln ADSCs

Many studies have also reported enhanced therapeutic efficacy of adipose stem cell
released extracellular vesicles and exosomes are being used to enhance wound healing in
DFUs [61–63]; it is imperative to further investigate the strategies to enhance the therapeutic
efficacy of stem cells and their synergistic or additive effects in a combinational approach
to promote angiogenesis and wound healing in chronic non-healing DFUs. In-depth
research involving exosomes (EVs) isolated from stem cells is also important because EVs
isolated from different types of stem cells may have differential effects on angiogenesis and
wound healing as reported by Pomatto et al. [64] that EVs isolated from bone marrow and
adipose mesenchymal stem cells have differential therapeutic effects on wound healing
Cells 2022, 11, 2287 10 of 14

and angiogenesis. Although these studies (Tables 2 and 3) suggest the promising role of
stem cells in inducing angiogenesis in the presence of hyperglycemia most of the studies
conducted on the murine model were done either on streptozotocin-induced diabetes
mellitus, type I diabetes, or genetically induced diabetic mice. However, type II diabetes is
common in human patients with DFUs. Having said that, it is warranted to design clinical
trials to establish the role of stem cells in enhancing angiogenesis in DFU wound healing.

5. Limitations and Future Perspectives

Limited cell viability, reduced cell number, limited proliferation, and differentiating
capacity of the stem cells are limiting factors while using stem cells. Stem cells may be
autologous or allogenic. Both autologous and allogeneic stem cells have shown improved
wound healing in human and animal models, but the pre-clinical and clinical data is still
limited and more well-planned studies with an increased number of subjects are warranted
for the feasibility of using stem cells in enhancing healing in DFUs [17]. Decreased viability
of stem cells due to late glycosylation end products in a hyperglycemic environment
diminishes the efficacy of stem cells in enhancing wound healing in DFUs [65]. However,
a study by Assis et al. [66] reported that the MSCs from diabetic patients have the same
potential for angiogenesis if they are seeded on decellularized micro fragments. The MSCs
were isolated from the bone marrow of distal tibial or femoral shafts from the amputated
limb. These results suggest the efficacy of autologous SMCs even in a diabetic patient in
enhancing angiogenesis during wound healing.
Administering an increased number of stem cells might be an alternative but is asso-
ciated with over-proliferation and tumorigenicity [67]. Administering stem cells with a
biomaterial carrier may mitigate the limitations associated with the number and viability
of stem cells but needs extensive research [19,20]. Administration of preconditioned stem
cells with photo-biomodulation is another strategy to enhance the viability and activity of
stem cells to enhance angiogenesis and wound healing [68–70]. With the background of the
complications associated with autologous MSCs, Palma et al. [71] reported that one specific
subpopulation derived from the Wharton’s jelly of the umbilical cord (ucMSC), the differ-
entiated mesenchymal cells (DMCs), has the potential of improving wound healing with
increased angiogenesis without any rejection of the transplanted cells in immunocompetent
mice. These results showed successful allogeneic transplantation of MSCs. Treating chronic
diabetic foot ulcers with adipose-derived stromal vascular fraction cell injections may be
a safe strategy to induce vascular repair, angiogenesis, and wound repair [72]. Although
the studies discussed in this article showed promising results favoring angiogenesis and
wound healing and the limitations of stem cells, the heterogeneity among the results of
various randomized clinical trials in human patients also warrants well-planned large-scale
randomized clinical trials to establish the best protocols, doses, transplant type (autologous,
allogenic, xenotransplant), cell types, cell source, and administration routes to enhance
angiogenesis and wound healing [19,20].

6. Conclusions
Stem cells have been proven beneficial in promoting angiogenesis and enhancing
wound healing both in vitro and in vivo but most of the in vivo studies were conducted
using animal models including mice, rats, and porcine. The results of various studies
showed heterogeneous results due to different sources of stem cells, route of delivery,
and stem cell properties like viability and proliferation after administration. Further, EVs
isolated from stem cells and a combination of stem cells with other strategies, as discussed
here, has also shown promising results. Based on this background, large-scale clinical trials
are warranted to harness the beneficial outcome of the lab findings and translate them to
the clinics.

Author Contributions: V.R.—conceptualize and wrote the initial draft, R.M. and D.K.A.—critically
reviewed and edited the manuscript, V.R., R.M. and D.K.A.—finalized the manuscript. All authors
have read and agreed to the published version of the manuscript.
Cells 2022, 11, 2287 11 of 14

Funding: The research work of Vikrant Rai is supported by intramural grant IMR Rai 12397B
from Western University of Health Sciences and of Devendra K. Agrawal by R01 HL144125 and
R01HL147662 from the National Heart, Lung, and Blood Institute, National Institutes of Health,
USA. The contents of this chapter are solely the responsibility of the authors and do not necessarily
represent the official views of the National Institutes of Health.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: As the corresponding author, I declare that this manuscript is original; that
the article does not infringe upon any copyright or other proprietary rights of any third party; that
neither the text nor the data have been reported or published previously. All the authors have no
conflict of interest and have read the journal’s authorship statement.

References
1. Tuttolomondo, A.; Maida, C.; Pinto, A. Diabetic foot syndrome: Immune-inflammatory features as possible cardiovascular
markers in diabetes. World J. Orthop. 2015, 6, 62–76. [CrossRef] [PubMed]
2. Oliver, T.I.; Mutluoglu, M. Diabetic Foot Ulcer. 2022. Available online: https://www.ncbi.nlm.nih.gov/books/NBK537328/
(accessed on 1 July 2022).
3. Uccioli, L.; Izzo, V.; Meloni, M.; Vainieri, E.; Ruotolo, V.; Giurato, L. Non-healing foot ulcers in diabetic patients: General and
local interfering conditions and management options with advanced wound dressings. J. Wound Care 2015, 24, 35–42. [CrossRef]
[PubMed]
4. Spampinato, S.F.; Caruso, G.I.; De Pasquale, R.; Sortino, M.A.; Merlo, S. The Treatment of Impaired Wound Healing in Diabetes:
Looking among Old Drugs. Pharmaceuticals 2020, 13, 60. [CrossRef] [PubMed]
5. Yang, P.; Pei, Q.; Yu, T.; Chang, Q.; Wang, D.; Gao, M.; Zhang, X.; Liu, Y. Compromised Wound Healing in Ischemic Type 2
Diabetic Rats. PLoS ONE 2016, 11, e0152068. [CrossRef]
6. Shofler, D.; Rai, V.; Mansager, S.; Cramer, K.; Agrawal, D.K. Impact of resolvin mediators in the immunopathology of diabetes
and wound healing. Expert Rev. Clin. Immunol. 2021, 17, 681–690. [CrossRef]
7. Theoret, C.L. The pathophysiology of wound repair. Vet. Clin. N. Am. Equine Pract. 2005, 21, 1–13. [CrossRef]
8. Honnegowda, T.M.; Kumar, P.; Udupa, E.G.P.; Kumar, S.; Kumar, U.; Rao, P. Role of angiogenesis and angiogenic factors in acute
and chronic wound healing. Plast. Aesthet. Res. 2015, 2, 243–249.
9. Li, J.; Zhang, Y.P.; Kirsner, R.S. Angiogenesis in wound repair: Angiogenic growth factors and the extracellular matrix. Microsc.
Res. Tech. 2003, 60, 107–114. [CrossRef]
10. Okonkwo, U.A.; Chen, L.; Ma, D.; Haywood, V.A.; Barakat, M.; Urao, N.; DiPietro, L.A. Compromised angiogenesis and vascular
Integrity in impaired diabetic wound healing. PLoS ONE 2020, 15, e0231962. [CrossRef]
11. Tonnesen, M.G.; Feng, X.; Clark, R.A. Angiogenesis in wound healing. J. Investig. Dermatol. Symp. Proc. 2000, 5, 40–46. [CrossRef]
12. DiPietro, L.A. Angiogenesis and wound repair: When enough is enough. J. Leukoc. Biol. 2016, 100, 979–984. [CrossRef] [PubMed]
13. Veith, A.P.; Henderson, K.; Spencer, A.; Sligar, A.D.; Baker, A.B. Therapeutic strategies for enhancing angiogenesis in wound
healing. Adv. Drug Deliv. Rev. 2019, 146, 97–125. [CrossRef] [PubMed]
14. Nosrati, H.; Aramideh Khouy, R.; Nosrati, A.; Khodaei, M.; Banitalebi-Dehkordi, M.; Ashrafi-Dehkordi, K.; Sanami, S.; Alizadeh,
Z. Nanocomposite scaffolds for accelerating chronic wound healing by enhancing angiogenesis. J. Nanobiotechnol. 2021, 19, 1.
[CrossRef] [PubMed]
15. Jarvis, C.I. Becaplermin (Regranex) for diabetic foot ulcers. Am. Fam. Physician 2008, 78, 255.
16. Verdi, J.; Shirian, S.; Saleh, M.; Khadem Haghighian, H.; Kavianpour, M. Mesenchymal Stem Cells Regenerate Diabetic Foot
Ulcers: A Review Article. World J. Plast. Surg 2022, 11, 12–22. [CrossRef] [PubMed]
17. Cao, Y.; Gang, X.; Sun, C.; Wang, G. Mesenchymal Stem Cells Improve Healing of Diabetic Foot Ulcer. J. Diabetes Res. 2017, 2017,
9328347. [CrossRef]
18. Yu, Q.; Qiao, G.H.; Wang, M.; Yu, L.; Sun, Y.; Shi, H.; Ma, T.L. Stem Cell-Based Therapy for Diabetic Foot Ulcers. Front. Cell Dev.
Biol. 2022, 10, 812262. [CrossRef]
19. Lopes, L.; Setia, O.; Aurshina, A.; Liu, S.; Hu, H.; Isaji, T.; Liu, H.; Wang, T.; Ono, S.; Guo, X.; et al. Stem cell therapy for diabetic
foot ulcers: A review of preclinical and clinical research. Stem Cell Res. Ther. 2018, 9, 188. [CrossRef]
20. Krasilnikova, O.A.; Baranovskii, D.S.; Lyundup, A.V.; Shegay, P.V.; Kaprin, A.D.; Klabukov, I.D. Stem and Somatic Cell Monother-
apy for the Treatment of Diabetic Foot Ulcers: Review of Clinical Studies and Mechanisms of Action. Stem Cell Rev. Rep. 2022.
[CrossRef]
21. Zarei, F.; Negahdari, B.; Eatemadi, A. Diabetic ulcer regeneration: Stem cells, biomaterials, growth factors. Artif. Cells Nanomed.
Biotechnol. 2018, 46, 26–32. [CrossRef]
22. Nolan, G.S.; Smith, O.J.; Jell, G.; Mosahebi, A. Fat grafting and platelet-rich plasma in wound healing: A review of histology from
animal studies. Adipocyte 2021, 10, 80–90. [CrossRef] [PubMed]
Cells 2022, 11, 2287 12 of 14

23. Shafiee, S.; Heidarpour, M.; Sabbagh, S.; Amini, E.; Saffari, H.; Dolati, S.; Meamar, R. Stem cell transplantation therapy for diabetic
foot ulcer: A narrative review. Asian Biomed. 2021, 15, 3–18. [CrossRef]
24. Nour, S.; Imani, R.; Chaudhry, G.R.; Sharifi, A.M. Skin wound healing assisted by angiogenic targeted tissue engineering: A
comprehensive review of bioengineered approaches. J. Biomed. Mater. Res. A 2021, 109, 453–478. [CrossRef] [PubMed]
25. Schonborn, M.; Laczak, P.; Pasieka, P.; Borys, S.; Plotek, A.; Maga, P. Pro- and Anti-Angiogenic Factors: Their Relevance in
Diabetic Foot Syndrome-A Review. Angiology 2022, 73, 299–311. [CrossRef]
26. O’Loughlin, A.; O’Brien, T. Topical stem and progenitor cell therapy for diabetic foot ulcers. In Stem Cells in Clinic and Research;
IntechOpen: London, UK, 2011.
27. Guillamat-Prats, R. The Role of MSC in Wound Healing, Scarring and Regeneration. Cells 2021, 10, 1729. [CrossRef]
28. Riedl, J.; Popp, C.; Eide, C.; Ebens, C.; Tolar, J. Mesenchymal stromal cells in wound healing applications: Role of the secretome,
targeted delivery and impact on recessive dystrophic epidermolysis bullosa treatment. Cytotherapy 2021, 23, 961–973. [CrossRef]
29. Yamada, H.; Naito, R.; Nishimura, M.; Kawakami, R.; Morinaga, E.; Morita, Y.; Shimizu, M.; Yoshimatsu, G.; Sawamoto, O.;
Matsumoto, S.; et al. Xenotransplantation of neonatal porcine bone marrow-derived mesenchymal stem cells improves diabetic
wound healing by promoting angiogenesis and lymphangiogenesis. Xenotransplantation 2022, 29, e12739. [CrossRef]
30. Zhou, J.; Wei, T.; He, Z. ADSCs enhance VEGFR3-mediated lymphangiogenesis via METTL3-mediated VEGF-C m(6)A modifica-
tion to improve wound healing of diabetic foot ulcers. Mol. Med. 2021, 27, 146. [CrossRef]
31. Gorecka, J.; Gao, X.; Fereydooni, A.; Dash, B.C.; Luo, J.; Lee, S.R.; Taniguchi, R.; Hsia, H.C.; Qyang, Y.; Dardik, A. Induced
pluripotent stem cell-derived smooth muscle cells increase angiogenesis and accelerate diabetic wound healing. Regen. Med.
2020, 15, 1277–1293. [CrossRef]
32. Irons, R.F.; Cahill, K.W.; Rattigan, D.A.; Marcotte, J.H.; Fromer, M.W.; Chang, S.; Zhang, P.; Behling, E.M.; Behling, K.C.; Caputo,
F.J. Acceleration of diabetic wound healing with adipose-derived stem cells, endothelial-differentiated stem cells, and topical
conditioned medium therapy in a swine model. J. Vasc. Surg 2018, 68, 115S–125S. [CrossRef]
33. Elsharawy, M.A.; Naim, M.; Greish, S. Human CD34+ stem cells promote healing of diabetic foot ulcers in rats. Interact. Cardiovasc
Thorac. Surg 2012, 14, 288–293. [CrossRef] [PubMed]
34. Barcelos, L.S.; Duplaa, C.; Krankel, N.; Graiani, G.; Invernici, G.; Katare, R.; Siragusa, M.; Meloni, M.; Campesi, I.; Monica, M.;
et al. Human CD133+ progenitor cells promote the healing of diabetic ischemic ulcers by paracrine stimulation of angiogenesis
and activation of Wnt signaling. Circ. Res. 2009, 104, 1095–1102. [CrossRef] [PubMed]
35. Kluth, M.A.; Kerstan, A.; Dieter, K.; Niebergall-Roth, E.; Klingele, S.; Jünger, M.; Hasslacher, C.; Daeschlein, G.; Stemler, L.;
Meyer-Pannwitt, U. Translational Development of ABCB5+ Dermal Mesenchymal Stem Cells for Therapeutic Induction of
Angiogenesis in Non-Healing Diabetic Foot Ulcers. 2022. Available online: https://assets.researchsquare.com/files/rs-1508134/
v1/012d9e57-5a5b-41c7-bdd5-621c7c557cc5.pdf?c=1649188762 (accessed on 1 July 2022).
36. Liu, Y.; Chen, J.; Liang, H.; Cai, Y.; Li, X.; Yan, L.; Zhou, L.; Shan, L.; Wang, H. Human umbilical cord-derived mesenchymal
stem cells not only ameliorate blood glucose but also protect vascular endothelium from diabetic damage through a paracrine
mechanism mediated by MAPK/ERK signaling. Stem Cell Res. Ther. 2022, 13, 258. [CrossRef]
37. Yan, J.; Liang, J.; Cao, Y.; El Akkawi, M.M.; Liao, X.; Chen, X.; Li, C.; Li, K.; Xie, G.; Liu, H. Efficacy of topical and systemic
transplantation of mesenchymal stem cells in a rat model of diabetic ischemic wounds. Stem Cell Res. Ther. 2021, 12, 220.
[CrossRef]
38. Shi, M.; Gao, Y.; Lee, L.; Song, T.; Zhou, J.; Yan, L.; Li, Y. Adaptive Gelatin Microspheres Enhanced Stem Cell Delivery and
Integration With Diabetic Wounds to Activate Skin Tissue Regeneration. Front. Bioeng. Biotechnol. 2022, 10, 813805. [CrossRef]
39. Takahashi, H.; Ohnishi, S.; Yamamoto, Y.; Hayashi, T.; Murao, N.; Osawa, M.; Maeda, T.; Ishikawa, K.; Sakamoto, N.; Funayama,
E. Topical Application of Conditioned Medium from Hypoxically Cultured Amnion-Derived Mesenchymal Stem Cells Promotes
Wound Healing in Diabetic Mice. Plast. Reconstr. Surg 2021, 147, 1342–1352. [CrossRef]
40. Wang, P.; Theocharidis, G.; Vlachos, I.S.; Kounas, K.; Lobao, A.; Shu, B.; Wu, B.; Xie, J.; Hu, Z.; Qi, S.; et al. Exosomes Derived
from Epidermal Stem Cells Improve Diabetic Wound Healing. J. Investig. Dermatol. 2022. [CrossRef]
41. Las Heras, K.; Royo, F.; Garcia-Vallicrosa, C.; Igartua, M.; Santos-Vizcaino, E.; Falcon-Perez, J.M.; Hernandez, R.M. Extracellular
vesicles from hair follicle-derived mesenchymal stromal cells: Isolation, characterization and therapeutic potential for chronic
wound healing. Stem Cell Res. Ther. 2022, 13, 147. [CrossRef]
42. Gondaliya, P.; Sayyed, A.A.; Bhat, P.; Mali, M.; Arya, N.; Khairnar, A.; Kalia, K. Mesenchymal Stem Cell-Derived Exosomes
Loaded with miR-155 Inhibitor Ameliorate Diabetic Wound Healing. Mol. Pharm. 2022, 19, 1294–1308. [CrossRef]
43. Yan, C.; Xv, Y.; Lin, Z.; Endo, Y.; Xue, H.; Hu, Y.; Hu, L.; Chen, L.; Cao, F.; Zhou, W.; et al. Human Umbilical Cord Mesenchymal
Stem Cell-Derived Exosomes Accelerate Diabetic Wound Healing via Ameliorating Oxidative Stress and Promoting Angiogenesis.
Front. Bioeng. Biotechnol. 2022, 10, 829868. [CrossRef]
44. Xiao, X.; Xu, M.; Yu, H.; Wang, L.; Li, X.; Rak, J.; Wang, S.; Zhao, R.C. Mesenchymal stem cell-derived small extracellular vesicles
mitigate oxidative stress-induced senescence in endothelial cells via regulation of miR-146a/Src. Signal. Transduct. Target. Ther.
2021, 6, 354. [CrossRef]
45. Liu, W.; Yuan, Y.; Liu, D. Extracellular Vesicles from Adipose-Derived Stem Cells Promote Diabetic Wound Healing via the
PI3K-AKT-mTOR-HIF-1alpha Signaling Pathway. Tissue Eng. Regen. Med. 2021, 18, 1035–1044. [CrossRef]
46. Qiu, J.; Shu, C.; Li, X.; Ye, C.; Zhang, W.C. Exosomes from linc00511-overexpressing ADSCs accelerates angiogenesis in diabetic
foot ulcers healing by suppressing PAQR3-induced Twist1 degradation. Diabetes Res. Clin. Pract. 2021, 180, 109032. [CrossRef]
Cells 2022, 11, 2287 13 of 14

47. Han, Z.F.; Cao, J.H.; Liu, Z.Y.; Yang, Z.; Qi, R.X.; Xu, H.L. Exosomal lncRNA KLF3-AS1 derived from bone marrow mesenchymal
stem cells stimulates angiogenesis to promote diabetic cutaneous wound healing. Diabetes Res. Clin. Pract. 2022, 183, 109126.
[CrossRef]
48. Hu, Y.; Tao, R.; Chen, L.; Xiong, Y.; Xue, H.; Hu, L.; Yan, C.; Xie, X.; Lin, Z.; Panayi, A.C.; et al. Exosomes derived from
pioglitazone-pretreated MSCs accelerate diabetic wound healing through enhancing angiogenesis. J. Nanobiotechnol. 2021, 19, 150.
[CrossRef]
49. Wei, Q.; Wang, Y.; Ma, K.; Li, Q.; Li, B.; Hu, W.; Fu, X.; Zhang, C. Extracellular Vesicles from Human Umbilical Cord Mesenchymal
Stem Cells Facilitate Diabetic Wound Healing Through MiR-17-5p-mediated Enhancement of Angiogenesis. Stem Cell Rev. Rep.
2022, 18, 1025–1040. [CrossRef]
50. Born, L.J.; Chang, K.H.; Shoureshi, P.; Lay, F.; Bengali, S.; Hsu, A.T.W.; Abadchi, S.N.; Harmon, J.W.; Jay, S.M. HOTAIR-Loaded Mesenchymal
Stem/Stromal Cell Extracellular Vesicles Enhance Angiogenesis and Wound Healing. Adv. Healthc. Mater. 2022, 11, e2002070. [CrossRef]
51. Seo, E.; Lim, J.S.; Jun, J.B.; Choi, W.; Hong, I.S.; Jun, H.S. Exendin-4 in combination with adipose-derived stem cells promotes
angiogenesis and improves diabetic wound healing. J. Transl. Med. 2017, 15, 35. [CrossRef]
52. Xue, J.; Sun, N.; Liu, Y. Self-Assembled Nano-Peptide Hydrogels with Human Umbilical Cord Mesenchymal Stem Cell Spheroids
Accelerate Diabetic Skin Wound Healing by Inhibiting Inflammation and Promoting Angiogenesis. Int. J. Nanomed. 2022, 17,
2459–2474. [CrossRef]
53. Zhou, W.; Zhao, X.; Shi, X.; Chen, C.; Cao, Y.; Liu, J. Constructing Tissue-Engineered Dressing Membranes with Adipose-Derived
Stem Cells and Acellular Dermal Matrix for Diabetic Wound Healing: A Comparative Study of Hypoxia- or Normoxia-Culture
Modes. Stem Cells Int. 2022, 2022, 2976185. [CrossRef]
54. Yang, H.Y.; Fierro, F.; Yoon, D.J.; Gallegos, A.; Osborn, S.L.; Nguyen, A.V.; Peavy, T.R.; Ferrier, W.; Talken, L.; Ma, B.W.; et al.
Combination product of dermal matrix, preconditioned human mesenchymal stem cells and timolol promotes wound healing in
the porcine wound model. J. Biomed. Mater. Res. B Appl. Biomater. 2022, 110, 1615–1623. [CrossRef]
55. Jiao, Y.; Chen, X.; Niu, Y.; Huang, S.; Wang, J.; Luo, M.; Shi, G.; Huang, J. Wharton’s jelly mesenchymal stem cells embedded in
PF-127 hydrogel plus sodium ascorbyl phosphate combination promote diabetic wound healing in type 2 diabetic rat. Stem Cell
Res. Ther. 2021, 12, 559. [CrossRef]
56. Ebrahim, N.; Dessouky, A.A.; Mostafa, O.; Hassouna, A.; Yousef, M.M.; Seleem, Y.; El Gebaly, E.; Allam, M.M.; Farid, A.S.;
Saffaf, B.A.; et al. Adipose mesenchymal stem cells combined with platelet-rich plasma accelerate diabetic wound healing by
modulating the Notch pathway. Stem Cell Res. Ther. 2021, 12, 392. [CrossRef]
57. Ni, X.; Shan, X.; Xu, L.; Yu, W.; Zhang, M.; Lei, C.; Xu, N.; Lin, J.; Wang, B. Adipose-derived stem cells combined with platelet-rich
plasma enhance wound healing in a rat model of full-thickness skin defects. Stem Cell Res. Ther. 2021, 12, 226. [CrossRef]
58. Huang, J.; Wu, S.; Wu, M.; Zeng, Q.; Wang, X.; Wang, H. Efficacy of the therapy of 5-aminolevulinic acid photodynamic therapy
combined with human umbilical cord mesenchymal stem cells on methicillin-resistant Staphylococcus aureus-infected wound in
a diabetic mouse model. Photodiagnosis Photodyn. Ther. 2021, 36, 102480. [CrossRef]
59. Pak, C.S.; Heo, C.Y.; Shin, J.; Moon, S.Y.; Cho, S.W.; Kang, H.J. Effects of a Catechol-Functionalized Hyaluronic Acid Patch
Combined with Human Adipose-Derived Stem Cells in Diabetic Wound Healing. Int. J. Mol. Sci. 2021, 22, 2632. [CrossRef]
60. Laiva, A.L.; O’Brien, F.J.; Keogh, M.B. SDF-1alpha Gene-Activated Collagen Scaffold Restores Pro-Angiogenic Wound Healing
Features in Human Diabetic Adipose-Derived Stem Cells. Biomedicines 2021, 9, 160. [CrossRef]
61. Chen, J.; Liu, R.; Huang, T.; Sun, H.; Jiang, H. Adipose stem cells-released extracellular vesicles as a next-generation cargo delivery
vehicles: A survey of minimal information implementation, mass production and functional modification. Stem Cell Res. Ther.
2022, 13, 182. [CrossRef]
62. Liu, W.J.; Liu, D.W. Research advances on mesenchymal stem cell-derived extracellular vesicles in promoting angiogenesis of
diabetic ulcers. Zhonghua Shao Shang Za Zhi 2022, 38, 393–399. [CrossRef]
63. An, Y.; Lin, S.; Tan, X.; Zhu, S.; Nie, F.; Zhen, Y.; Gu, L.; Zhang, C.; Wang, B.; Wei, W.; et al. Exosomes from adipose-derived stem
cells and application to skin wound healing. Cell Prolif. 2021, 54, e12993. [CrossRef]
64. Pomatto, M.; Gai, C.; Negro, F.; Cedrino, M.; Grange, C.; Ceccotti, E.; Togliatto, G.; Collino, F.; Tapparo, M.; Figliolini, F.; et al.
Differential Therapeutic Effect of Extracellular Vesicles Derived by Bone Marrow and Adipose Mesenchymal Stem Cells on
Wound Healing of Diabetic Ulcers and Correlation to Their Cargoes. Int. J. Mol. Sci. 2021, 22, 3851. [CrossRef]
65. Wang, Z.; Li, H.; Zhang, D.; Liu, X.; Zhao, F.; Pang, X.; Wang, Q. Effect of advanced glycosylation end products on apoptosis in
human adipose tissue-derived stem cells in vitro. Cell Biosci. 2015, 5, 3. [CrossRef]
66. Assis, A.; Gellman, Y.N.; Cahn, A.; Haze, A.; Camargo, S.; Mitrani, E. Angiogenic potential of mesenchymal stem cells derived
from patients with diabetes seeded on decellularized micro fragments. J. Diabetes Complicat. 2021, 35, 108001. [CrossRef]
67. Mathew, E.; Brannon, A.L.; Del Vecchio, A.; Garcia, P.E.; Penny, M.K.; Kane, K.T.; Vinta, A.; Buckanovich, R.J.; di Magliano, M.P.
Mesenchymal Stem Cells Promote Pancreatic Tumor Growth by Inducing Alternative Polarization of Macrophages. Neoplasia
2016, 18, 142–151. [CrossRef]
68. Ahmadi, H.; Amini, A.; Fadaei Fathabady, F.; Mostafavinia, A.; Zare, F.; Ebrahimpour-Malekshah, R.; Ghalibaf, M.N.; Abrisham,
M.; Rezaei, F.; Albright, R.; et al. Transplantation of photobiomodulation-preconditioned diabetic stem cells accelerates ischemic
wound healing in diabetic rats. Stem Cell Res. Ther. 2020, 11, 494. [CrossRef]
Cells 2022, 11, 2287 14 of 14

69. Moradi, A.; Zare, F.; Mostafavinia, A.; Safaju, S.; Shahbazi, A.; Habibi, M.; Abdollahifar, M.A.; Hashemi, S.M.; Amini, A.;
Ghoreishi, S.K.; et al. Photobiomodulation plus Adipose-derived Stem Cells Improve Healing of Ischemic Infected Wounds in
Type 2 Diabetic Rats. Sci. Rep. 2020, 10, 1206. [CrossRef]
70. Kim, Y.J.; Jeon, H.R.; Kim, S.W.; Kim, Y.H.; Im, G.B.; Im, J.; Um, S.H.; Cho, S.M.; Lee, J.R.; Kim, H.Y.; et al. Lightwave-reinforced
stem cells with enhanced wound healing efficacy. J. Tissue Eng. 2021, 12, 20417314211067004. [CrossRef]
71. Palma, M.B.; Luzzani, C.; Andrini, L.B.; Riccillo, F.; Buero, G.; Pelinski, P.; Inda, A.M.; Errecalde, A.L.; Miriuka, S.; Carosella,
E.D.; et al. Wound Healing by Allogeneic Transplantation of Specific Subpopulation From Human Umbilical Cord Mesenchymal
Stem Cells. Cell Transplant. 2021, 30, 963689721993774. [CrossRef]
72. Carstens, M.H.; Quintana, F.J.; Calderwood, S.T.; Sevilla, J.P.; Rios, A.B.; Rivera, C.M.; Calero, D.W.; Zelaya, M.L.; Garcia, N.;
Bertram, K.A.; et al. Treatment of chronic diabetic foot ulcers with adipose-derived stromal vascular fraction cell injections: Safety
and evidence of efficacy at 1 year. Stem Cells Transl. Med. 2021, 10, 1138–1147. [CrossRef]