Netrin1‐Enriched Exosomes From Genetically Modified ADSCs as a Novel Treatment for Diabetic Limb Ischemia

Abstract Diabetic limb ischemia (DLI) is a frequent complication of diabetes and the leading cause of non‐traumatic amputation. Traditional treatments like stent placement and bypass surgery may not suit all patients. Exosome transplantation has emerged as a promising therapy. Netrin1, a protective cardiovascular factor, has an unclear role in DLI. This study investigates the role of Netrin1 in DLI patients and evaluates the therapeutic potential of exosomes derived from Netrin1‐overexpressing adipose‐derived stem cells (N‐ADSCs). The expression of Netrin1 is significantly decreased in both endothelial cells and serum of DLI patients, highlighting its potential as a biomarker or therapeutic target. In vitro, Netrin1‐enriched exosomes (N‐Exos) promoted human umbilical vein endothelial cell (HUVEC) proliferation, migration, tube formation, and increased resistance to apoptosis under high glucose conditions. These protective effects are mediated through PI3K/AKT/eNOS and MEK/ERK pathways, and N‐Exos further facilitated macrophage polarization from M1 to M2. In vivo, N‐Exos demonstrates superior therapeutic effects over ADSC exosomes (Exos), including enhanced angiogenesis, improved collateral artery remodeling, reduced inflammation, and muscle protection. Collectively, these findings identify Netrin1 as a critical factor in DLI and underscore its significance in disease progression and therapeutic strategies. N‐Exos offers a promising non‐cellular therapeutic approach for the treatment of DLI.