99mTc-rhAnnexin V-128 Planar and SPECT Imaging of Apoptosis in Asymptomatic Or Previously Symptomatic With TIA Patients With Carotid Atherosclerotic Plaque
Phase: PHASE2
Conditions: Carotid Artery Plaque
Sponsor: Advanced Accelerator Applications

AAA-Annexin-04 
Page 1 of 45 
Study Protocol 
Confidential 
Version 5.0, 2 February 2018 
Study Protocol 
Protocol Number 
AAA-Annexin-04 / NCT02667457 
Investigational Product 
Kit for the preparation of 99mTc-rhAnnexin V-128 
Active substance 
rhAnnexin V-128 
Radiolabelled Imaging 
Product 
99mTc-rhAnnexin V-128 
Trial Phase 
Proof of Concept and Phase II 
Trial Title 
99mTc-rhAnnexin V-128 Planar and SPECT Imaging of 
Apoptosis in Asymptomatic Or Previously Symptomatic with 
TIA Patients with Carotid Atherosclerotic Plaque 
Short Trial Title 
99mTc-rhAnnexin V-128 imaging for Carotid Atherosclerosis 
Version and Date 
v.5.0 dated 2 February2018
Investigators 
Principal 
Investigator:  
, MD, FRCPC, FACC 
Co-Investigators: 
, MD, FRCPC, FACC 
, MD, FRCPC, FACC 
, PhD, MD 
, PhD 
Trial Sponsor 
Advanced Accelerator Applications 
The concepts and information contained herein or generated during the study 
are considered proprietary and shall not be disclosed in whole or in part without 
the expressed written consent of Advanced Accelerator Applications. 
This study is to be completed according to the guidelines of Good Clinical Practice 
(GCP) and conducted in full compliance with the World Medical Association Declaration 
of Helsinki and its most recent amendments. 

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SPONSOR SIGNATORY APPROVAL PAGE 
 
 
PROTOCOL TITLE:99mTc-rhAnnexin V-128 Planar and SPECT Imaging of Apoptosis in 
Asymptomatic Or Previously Symptomatic with TIA with Carotid 
Atherosclerotic Plaque 
 
PROTOCOL NUMBER: AAA-Annexin-04, Version 5.0, 2 February 2018 
 
Signatures on this page denote approval of the study protocol outline by the 
respective Sponsor Department 
 
 
Role 
Name and contact 
Date & Signature 
 
 
, PhD, DSc 
Advanced Accelerator Applications SA 
Tel: 
 
Cell: 
 
E-mail: 
 
 
 
, MD, 
PhDAdvanced Accelerator Applications SA  
Tel : 
 
E-mail: 
 
 
 
, PharmD 
Advanced Accelerator Applications SA 
Tel:  
 
Fax: 
 
Cell: 
 
E-mail: 
 
 
 
 
 

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Study Protocol 
 
Confidential 
Version 5.0, 2 February 2018 
 
INVESTIGATOR ENDORSEMENT PAGE 
 
I agree to conduct the study as outlined in the protocol entitled “99mTc-rhAnnexin V-128 Planar 
and SPECT Imaging of Apoptosis in Asymptomatic Or Previously Symptomatic with TIA Patients 
with Carotid Atherosclerotic Plaque” in accordance with the guidelines and all applicable 
government regulations. These guidelines and regulations include, but are not limited to:  
 
1. Permission to allow the Sponsor and the regulatory agencies to inspect study facilities and 
pertinent records at reasonable times and in a reasonable manner that ensures participant 
confidentiality.  If this study is to be inspected by a regulatory agency, the Sponsor should 
be notified as soon as possible; 
 
2. Submission of the proposed clinical investigation, including the protocol and the consent 
form to a duly constituted Research Ethic Board (REB) as well as Health Canada 
(regulatory authority) for approval and acquisition of written approval prior to study conduct; 
 
3. Use of written informed consent that is obtained prior to study conduct and that contains all 
the elements of consent as specified in the federal regulations and has been previously 
approved by the Sponsor, the REB and Health Canada; 
 
4. Submission of any proposed change in or deviation from the protocol to the REB to be 
approved by the Sponsor. Any proposed changes or deviations from the protocol may 
require that the informed consent also reflect such changes or deviations and that the 
revised informed consent be approved by the REB and Health Canada; 
 
5. Documentation and explanation of individual protocol deviations on the appropriate case 
report form page or in letters to the Sponsor; 
 
6. Reports of serious adverse events to the Sponsor/CRO within 24 hours by telephone and a 
written report of the serious adverse event within 72 hours after the Investigator’s initial 
receipt of the information; 
 
7. Reporting of Serious Adverse Events (SAE) according to ICH/GCP and regulator 
standards. SAE will be reported from the signing of the informed consent and followed until 
resolution or determined to be not clinically significant. 
 
8. Submission of timely progress reports to the REB and Sponsor at appropriate intervals on a 
schedule determined by the REB. 
 
Regulations require an Investigator to prepare and maintain adequate and accurate case 
histories designed to record all observations and other data (such as investigational product 
accountability) pertinent to the investigation on each individual enrolled in the study. These 
records must be maintained by the Investigator for a minimum period of 25 years or a period of 
time determined by the Sponsor following the date a marketing application is approved for the 
indication for which it is being investigated, or, if no application is to be filed or if the application 
is not approved for such indication, a minimum of 25 years or a period of time determined by the 
Sponsor after the investigation is discontinued and the appropriate regulatory authorities are 
notified. 
 
 

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Study Protocol 

Confidential 
Version 5.0, 2 February 2018 
 
 
In addition, I agree to provide all the information requested in the case report form in a manner 
to assure legibility and accuracy. To this end, I shall carefully follow the instructions for 
completing case report forms. 
 
I also agree that all information provided to me by the Sponsor, including protocols, case report 
forms, and verbal and written information, will be kept strictly confidential and confined to the 
clinical personnel involved in conducting the study. It is recognized that this information may be 
related in confidence to the REB/regulatory authorities. I also understand that reports of 
information about the study or its progress will not be provided to anyone who is not involved in 
the study other than to the Principal Investigator, or in confidence to the REB or to the legally 
constituted regulatory authorities. 
 
 
 
 
Principal Investigator Signature
Date of Signature
 
 
 
 
 

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Table of Contents 
SPONSOR SIGNATORY APPROVAL PAGE 
2 
INVESTIGATOR ENDORSEMENT PAGE 
3 
1. 
Study Synopsis 
7 
2. 
List of abbreviations 
12 
3. 
Background and Rationale 
14 
4. 
Study Objectives 
15 
5. 
Hypotheses 
16 
5.1 
Primary Hypothesis 
16 
5.2 
Secondary Hypotheses 
16 
6. 
Study Design 
16 
7. 
End of Study 
16 
8. 
Study Population 
16 
8.1 
Inclusion criteria 
16 
8.2 
Exclusion criteria 
17 
8.3 
Source of Study Population 
17 
8.4 
Participants Study Identification 
17 
8.5 
Premature Discontinuation 
17 
8.6 
Prohibitions and Restrictions 
18 
9. 
Investigational Product, Dose and Mode of Administration 
18 
9.1 
Description of Investigational Product 
18 
9.2 
Handling, Preparation and Storage 
19 
9.3 
Investigational Product Accountability 
19 
9.4 
Investigational Product Dose, Mode of Administration 
20 
10. 
Study Procedures 
20 
10.1 
Baseline Assessments 
20 
10.2 
Laboratory Assessments 
20 
10.3 
99mTc-rhAnnexin V-128 SPECT Imaging of the Carotid Arteries and Aorta and Image 
Analysis 
21 
10.4 
99mTc-rhAnnexin V-128 Radiation Risk Assessment 
22 
10.5 
Ultrasound Examination 
22 
11. 
Data Monitoring Committee 
23 
12. 
Statistical methods 
23 

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12.1 
Sample size and analysis 
23 
12.2 
General statistical considerations 
23 
12.3 
Demographics and Other Participant Characteristics 
24 
12.4 
Efficacy 
24 
12.5 
Safety 
24 
12.5.1 
Adverse Events / Serious Adverse Events 
24 
12.5.2 
Laboratory Tests 
24 
13. 
Adverse Events and other Safety Aspects 
25 
13.1 
Definition of Adverse Events 
25 
13.2 
Definition of Serious Adverse Events 
25 
13.3 
Procedure in Case of Pregnancy 
25 
13.4 
New Safety Information Affecting the Conduct of the Study 
25 
13.5 
Data Monitoring and Safety 
26 
14. 
Termination of the study 
26 
15. 
Operational, Ethical and Administrative Considerations 
26 
15.1 
Clinical Study Monitoring and Audit 
26 
15.2 
Ethics and Protection of Participant Confidentiality 
27 
15.2.1 
Ethical Conduct of Clinical Study 
27 
15.2.2 
Authorities 
28 
15.3 
Arrangement for Use of Information and Publication of Clinical Study Data 
28 
15.4 
Records Related to the Clinical Study and Confidentiality 
29 
15.5 
Protocol Amendment and/or Revision and Protocol Deviations 
29 
15.6 
Qualification of the Investigators and delegation of responsibility 
29 
15.7 
Conflict of Interest and Financial Disclosure 
30 
15.8 
Investigator and Manufacturer Indemnity 
30 
16. 
REFERENCES 
31 
APPENDIX I – RADIOLABELING PROCEDURE OF RH-ANNEXIN V-128 AND QUALITY 
CONTROLS 
34 
APPENDIX II – SAE FORM 
ERROR! BOOKMARK NOT DEFINED. 
APPENDIX III – PREGNANCY FORM 
42 

 
 

A A A- A n n e xi n- 0 4 
 
P a g e 7 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
 
1.  
St u d y S y n o p si s 
 
I n v e sti g ati o n al 
M e di ci n al 
Pr o d u ct 
Kit f or t h e Pr e p ar ati o n of 9 9 m T c R e c o m bi n a nt H u m a n A n n e xi n V- 1 2 8 f or 
I nj e cti o n 
Titl e of t h e st u d y 
9 9 m T c-r h A n n e xi n V- 1 2 8 Pl a n ar a n d S P E C T I m a gi n g of A p o pt o si s i n 
A s y m pt o m ati c Or Pr e vi o u sl y S y m pt o m ati c wit h TI A P ati e nt s wit h C ar oti d 
At h er o s cl er oti c Pl a q u e 
Pri n ci p al 
I n v e sti g at or a n d 
St u d y Sit e 
Dr. 
, M D, F R C P C, F A C C 
Ott a w a H e art I n stit ut e, Ott a w a H o s pit al, Di vi si o n of N u cl e ar M e di ci n e,  
4 0 R u s ki n Str e et, Ott a w a, O nt ari o, C a n a d a K 1 Y 4 W 7 
S p o n s or 
A d v a n c e d A c c el er at or A p pli c ati o n s 
St u d y I n di c ati o n 
P ati e nt s wit h di a g n o s e d a s y m pt o m ati c c ar oti d at h er o s cl er oti c pl a q u e 
O bj e cti v e s 
Pri m ar y O bj e cti v e s 
•  
T o d et er mi n e t h e f e a si bilit y of i m a gi n g a p o pt oti c a cti vit y i n c ar oti d 
at h er o s cl er oti c pl a q u e s of a s y m pt o m ati c p ati e nt s or p ati e nt s t h at h a v e 
b e e n pr e vi o u sl y s y m pt o m ati c wit h TI A o nl y wit h si g nifi c a nt c ar oti d art er y 
di s e a s e b y u si n g 9 9 m T c-r h A n n e xi n V- 1 2 8 a n d t o r e p ort t h e pr e v al e n c e of 
a b n or m al 9 9 m T c- r h A n n e xi n V- 1 2 8 s c a n s. 
 
S e c o n d ar y O b j e cti v e s: 
•  
T o e st a bli s h t h e u pt a k e of 9 9 m T c-r h A n n e xi n V- 1 2 8 i n a c o ntr ol gr o u p of 
p arti ci p a nt s wit h n or m al c ar oti d ultr a s o u n d s. 
•  
T o 
a s s e s s t h e 
9 9 m T c-r h A n n e xi n 
V- 1 2 8 
u pt a k e 
v er s u s 
pl a q u e( s) 
e c h o g e ni cit y  a n d e c h ol u c e n c y. 
•  
T o m e a s ur e t h e a orti c u pt a k e of 9 9 m T c-r h A n n e xi n V- 1 2 8 a n d a s s e s s t h e 
c orr el ati o n wit h it s c ar oti d u pt a k e. 
R ati o n al e 
A n n e xi n V i s a n e n d o g e n o u s h u m a n pr ot ei n t h at bi n d s t o p h o s p h ati d yl s eri n e 
( P S), a c o n stit uti v e a ni o ni c p h o s p h oli pi d of t h e pl a s m a 
m e m br a n e of all 
m a m m ali a n c ell s, t h at i s o nl y e x pr e s s e d o nl y o n t h e s urf a c e of p h y si ol o gi c all y 
str e s s e d, d e p ol ari z e d, or a p o pt oti c c ell s. T e c h n eti u m- 9 9 m ( 9 9 m T c) i s a m e di c al 
i s ot o p e 
wi d el y u s e d i n di a g n o sti c i m a gi n g. 9 9 m T c-l a b el e d a n n e xi n V h a s 
d e m o n str at e d t h e a bilit y t o i m a g e c ell ul ar str e s s, m e m br a n e d e p ol ari z ati o n (i. e. 
a c ut e a n d c hr o ni c p ai n i n a ni m al m o d el s a n d c ell c ult ur e), a p o pt o si s a n d 
n e cr o si s i n a v ari et y of i nfl a m m at or y di s e a s e s i n cl u di n g at h er o s cl er o si s, 
m y o c ar diti s, a c ut e h e art tr a n s pl a nt r ej e cti o n, r h e u m at oi d art hriti s, pr o st h eti c j oi nt 
i nf e cti o n a n d Cr o h n’ s di s e a s e i n b ot h a ni m al m o d el s a n d h u m a n s. 
Pl a n n e d n u m b er 
of p arti ci p a nt s 
T hirt y fi v e e v al u a bl e a s y m pt o m ati c or pr e vi o u sl y s y m pt o m ati c wit h TI A o nl y 
p ati e nt s wit h di a g n o s e d c ar oti d at h er o s cl er oti c pl a q u e. I n a d diti o n, a c o ntr ol 
gr o u p of 1 0 p arti ci p a nt s wit h n or m al c ar oti d ultr a s o u n d i m a gi n g will b e e nr oll e d.  

A A A- A n n e xi n- 0 4 
 
P a g e 8 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
Fift e e n p ati e nt s a n d 5 n or m al s will b e r e cr uit e d i n t h e fir st p art of t h e tri al, a s a 
Pr o of of C o n c e pt ( P o C). T h e P o C st u d y will a s s e s s t h e i m a gi n g p ot e nti al of 
9 9 m T c-r h A n n e xi n V- 1 2 8 i n t er m s of i m a gi n g q u alit y, u pt a k e a n d 
m e di c al 
r el e v a n c e t o e n a bl e t h e d e ci si o n t o c o nti n u e t h e cli ni c al i n v e sti g ati o n wit h t h e 
r e m ai ni n g 2 0 p ati e nt s. 
St u d y d e si g n a n d 
M et h o d ol o g y 
T hi s i s a si n gl e- c e ntr e, si n gl e d o s e, P o C, P h a s e II st u d y. P arti ci p a nt s w h o h a v e 
si g n e d t h e i nf or m e d c o n s e nt a n d ar e eli gi bl e t o p arti ci p at e i n t h e st u d y will 
u n d er g o t h e f oll o wi n g a s s e s s m e nt s: 
•  
A s cr e e ni n g vi sit will b e c o n d u ct e d wit hi n 8 w e e k s 9 9 m T c-r h A n n e xi n V-
1 2 8 i m a gi n g. Eli gi bl e a n d c o n s e nti n g p arti ci p a nt s will u n d er g o a li mit e d 
p h y si c al e x a mi n ati o n ( h ei g ht, w ei g ht, B MI), vit al si g n s ( s y st oli c a n d 
di a st oli c bl o o d pr e s s ur e, h e art r at e), bl o o d a n al y si s a n d uri n al y si s. T h e 
f oll o wi n g bl o o d a n al y si s 
will b e c o n d u ct e d: 
C B C 
wit h a ut o m at e d 
diff er e nti al, g e n er al c h e mi str y p a n el ( S M A- 2 0) i n cl u di n g, P T/ P T T, I N R 
(i nt er n ati o n al n or m ali z e d r ati o f or P T v al u e s) a n d a s s e s s m e nt of a nti-
a n n e xi n V- 1 2 8 a nti b o di e s. 
•  
C ar oti d ultr a s o u n d will b e c arri e d o ut wit hi n 8 w e e k s pri or t o t h e 9 9 m T c-
r h A n n e xi n V- 1 2 8 pl a n ar a n d S P E C T/ C T i m a gi n g. I m a gi n g vi sit: pl a n ar 
a n d d e di c at e d S P E C T/ C T i m a gi n g of t h e c ar oti d s a n d  a ort a will b e d o n e 
6 0 mi n ut e s aft er i nj e cti o n of tr a c er, a n d 1 2 0 mi n ut e s aft er i nj e cti o n. Vit al 
si g n s a s s e s s m e nt/ p arti ci p a nt m o nit ori n g will b e d o n e t hr o u g h o ut t h e vi sit.  
•  
Wit hi n 2 4 h o ur s aft er t h e a d mi ni str ati o n of 9 9 mT c-r h A n n e xi n V- 1 2 8, 
p arti ci p a nt s will b e c all e d f or t h e a s s e s s m e nt of p o s si bl e a d v er s e e v e nt s.  
•  
3 0 +/- 3 d a y s p o st 9 9 m T c-r h A n n e xi n V- 1 2 8 i nj e cti o n, all p arti ci p a nt s will 
r et ur n t o cli ni c f or a fi n al bl o o d s a m pli n g t o r ul e o ut t h e d e v el o p m e nt of 
a nti- a n n e xi n V- 1 2 8 a nti b o di e s.  T h e f oll o wi n g bl o o d a n al y si s will al s o b e 
c o n d u ct e d: C B C wit h a ut o m at e d diff er e nti al, g e n er al c h e mi str y p a n el 
( S M A- 2 0) i n cl u di n g, P T/ P T T, a n d I N R. 
•  
O n c e t h e fir st 1 5 p ati e nt s a n d 5 n or m al s h a v e b e e n a d mi ni st er e d wit h 
9 9 m T c-r h A n n e xi n V- 1 2 8 a n d h a v e p erf or m e d t h e i m a gi n g vi sit s, t h e D at a 
M o nit ori n g C o m mitt e e will r e vi e w t h e i m a g e s. T h e vi s u al a s s e s s m e nt of 
t h e s c a n s i n t h e s e fir st 2 0 p arti ci p a nt s will s u p p ort t h e c o nti n u ati o n or t h e 
t er mi n ati o n of t h e P h a s e II st u d y. 
Tr e at m e nt 
Aft er r e c o n stit uti o n a n d r a di ol a b eli n g, 9 9 m T c-r h A n n e xi n V- 1 2 8 i s a d mi ni st er e d a s 
a si n gl e i ntr a v e n o u s b ol u s of 3 5 0 M B q +/- 1 0 % at t h e i m a gi n g vi sit ( D a y 0). 
I n cl u si o n/ 
e x cl u si o n crit eri a  
I n cl u si o n crit eri a 
 
F or all p arti ci p a nt s: 
1. 
M al e s a n d f e m al e s a g e 1 8 y e ar s or gr e at er  
2. 
A bl e a n d willi n g t o c o m pl y wit h t h e st u d y pr o c e d ur e s 
3. 
N e g ati v e pr e g n a n c y t e st f or w o m e n of c hil d b e ari n g p ot e nti al at 
s cr e e ni n g a n d o n t h e d a y of a d mi ni str ati o n of 9 9 m T c-r h A n n e xi n V- 1 2 8.  
 

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For participants with carotid artery disease: 
4. Evidence of 50% or more carotid stenosis in one or more carotid arteries 
on carotid ultrasound within 2 years; 
 
For control participants: 
4.  No significant carotid artery disease on carotid ultrasound; 
 
Exclusion criteria 
1. Previous carotid stenting or endarterectomy or stroke; 
2. Diagnosis of vasculitis, dissection, or non-atherosclerotic carotid disease 
(Ehlers-Danlos, Marfans); 
3. Pregnancy or lactation; 
4. History of any disease or relevant physical or psychiatric condition or 
abnormal physical finding which may interfere with the study objectives 
at the investigator judgment; 
5. Know hypersensitivity to the investigational product or any of its 
components; 
6. Claustrophobia or inability to lie still in a supine position; 
7. Participation in another clinical trial within 4 weeks before study inclusion, 
except for patients who have participated or who are currently 
participating in a study without any study drug administration; 
8. Unwillingness to provide consent. 
Study duration 
and assessments
Maximum 3 months (+/- 3 days) including the screening period for an individual 
participant 
Safety 
Venous blood samples will be drawn for each participant at screening and at 30 
+/- 3 days post IP administration for laboratory analysis (CBC with diff., SMA-20, 
PT/PTT, INR).  
To rule out development of anti-annexin V-128 antibodies, venous blood 
samples will also be drawn for each participant at screening and 30 +/- 3 days 
post 99mTc-rhAnnexin V-128 injection. Assays for anti-rhAnnexin V-128 IgG and 
IgM antibodies will be performed in serum samples by ELISA. For this purpose, 
10 mL of blood will be collected for each assay. 
24 hours post IP injection, each participant will be called to review any signs or 
symptoms of AEs. If any, adverse event(s) will be reported and recorded in the 
Electronic Case Report Form (e-CRF). 
All participants will undergo a physical examination (height, weight, BMI) and 
vital signs (systolic and diastolic blood pressure, heart rate) at screening visit 
and before and after injection of the radiotracer. 
Adverse events will be collected in the e-CRF. 

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Statistics 
A sample size of 30 patients produces a 96 to 98% confidence interval equal to 
the sample proportion plus or minus 0.17 to 0.20 when the estimated proportion 
is 0.3 to 0.5. Sample size was also estimated for the comparison of 99mTc-rh-
Annexin-V 128 uptake in asymptomatic patients with carotid disease versus 
controls using a 5% significance level and power of 95%. Based on the results 
from the Phase I clinical trial in 12 healthy volunteers and by allowing attrition, 
we plan to recruit 10 participants in the control group and 35 patients with carotid 
plaque. 
Among the 35 patients and 10 normals, 15 patients from the disease group and 
5 normals from the control group will be enrolled in the PoC phase, which is 
believed to provide sufficient data to demonstrate the potential of 99mTc-
rhAnnexin V-128 imaging in carotid atherosclerotic plaque. 
 
Primary endpoint of PoC: 
The feasibility of imaging apoptotic activity in carotid atherosclerotic plaques 
using 99mTc-rhAnnexin V-128 will be assessed by the data monitoring committee 
(visual image review and consensus). The frequency and severity of abnormal 
carotid scans will be determined in the patient and normal groups. 
 
Primary endpoint of Phase II: 
To determine the prevalence of abnormal 99mTc-rhAnnexin V-128 planar and 
SPECT/CT imaging. 
 
Secondary endpoints: 
Descriptive statistics of 99mTc-rhAnnexin V-128 uptake in control participants will 
be presented by areas of interest to assess the background uptake profile. 
99mTc-rhAnnexin V-128 carotid uptake will be related to the ultrasound data of 
plaque echogenicity and echolucency. 
99mTc-rhAnnexin V-128 uptake in carotids will be correlated to aortic uptake in all 
participants. 
 
Safety: 
Adverse events will be listed on an individual basis, including relationship, and 
severity, and will be summarized by System Organ Class (SOC) and Preferred 
Term (PT). Participants with more than one adverse event within a particular 
SOC and PT will be counted only once for that SOC and PT. The incidence of 
adverse events will also be summarized by severity. 
All other safety variables will be tabulated at each measuring time. Hematology, 
clinical chemistry, urinalysis and immunogenicity data will be analysed with 
respect to the normal ranges of values provided by the laboratory. Similarly, 
descriptive statistics will also be provided for vital signs, physical examination, 
etc. 

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Table 1 – Visit Schedule 
 
 
1 Within 24 hours after injection of 99mTc-rh-Annexin V-128, each participant will be called to 
review any signs or symptoms of AEs. 
 
2 Anti-rhAnnexin V-128 IgG and IgM antibodies will be quantified in serum samples by ELISA. For 
this purpose 10 mL blood samples will be collected at screening and Day 30 (±3 days) post 
administration of investigation product. Serum will be prepared, divided into six aliquots and 
frozen (-80°C). Three out of six serum samples per time-point will then be shipped to the 
 central laboratory. 
 
3 Within 8 weeks prior to 99mTc-rh-Annexin V-128 imaging. 
 
 
 
Study Procedures 
Screening 
(Within 8 
weeks prior 
to Day 0)
Planar and 
SPECT/CT 
Visit  
(Day 0) 
24 hours 
post IP 
injection1 
30 ± 3 days 
post IP 
injection 
(Day 30)
Written informed consent 
x 
 
 
 
Inclusion/exclusion criteria 
x 
x 
 
 
Medical history 
x 
 
 
 
Concomitant medications  
x 
x 
x 
x 
Physical examination 
(height, weight, BMI) 
x 
x 
 
 
Vital signs 
(BP, HR) 
x 
x 
 
 
Lab analysis (hematology, 
PT/PTT/INR, biochemistry, urine)
x 
 
 
x 
Immunogenicity by ELISA2 
x 
 
 
x 
Pregnancy test 
x 
x 
 
 
Carotid ultrasound3 
x 
 
 
 
rh-Annexin V-128 administration  
 
x 
 
 
Planar & SPECT/CT imaging 
 
x 
 
 
Adverse events assessment 
 
x 
x 
x 

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2. List of abbreviations 
 
AE 
BUN 
e-CRF 
CRO 
CRP 
CT 
DMC 
ELISA 
ESR 
FDA 
FDG 
GCP 
Hb 
HPLC 
IBD 
ICF 
ICP-MS 
ICP-OES 
ICRP 
IEC 
IL-6 
IMP 
INR 
IRB 
ITLC 
MBq 
MIRD 
MCV 
MedDRA 
NOAEL 
Adverse Event 
Blood Urea Nitrogen 
Electronic Case Report Form 
Clinical Research Organization 
C-Reactive Protein 
Computed Tomography 
Data Monitoring Committee 
Enzyme-Linked Immuno-absorbent Assay 
Erythrocyte Sedimentation Rate 
Food and Drug Administration 
18-fluorodeoxyglucose 
Good Clinical Practice 
Hemoglobin 
High-Performance Liquid Chromatography 
Inflammatory Bowel Disease 
Informed Consent Form 
Inductively Coupled Plasma Mass Spectrometry 
Inductively Coupled Plasma Optical Emission Spectrometry 
International Commission on Radiological Protection 
Independent Ethics Committee 
Interleukine-6 
Investigational Medicinal Product 
International Normalized Ratio 
Institutional Review Board 
Instant Thin Layer Chromatography 
Mega Becquerel 
Medical Internal Radiation Dose 
Mean Corpuscular Volume 
Medical Dictionary For Regulatory Activities 
No Observed Adverse Effect Level 

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PET 
PBS 
PoC 
PS 
PT 
PTT 
PV 
QA 
QC 
RBC 
RCP 
REB 
ROI 
RR 
 
SAE 
SEC-HPLC  
SD 
SOP 
SPECT 
TBR 
TLC 
US 
UV/Vis 
WBC 
WFI 
WHO 
VOI 
Positron Emission Tomography 
Phosphate Buffered Saline 
Proof of Concept 
Phosphatidylserine 
Prothrombin Time 
Partial Thromboplastin Time 
Pharmaco Vigilance 
Quality Assurance 
Quality Control 
Red Blood Cell 
Radiochemical Purity 
Research Ethic Board 
Region of Interest 
Respiratory Rate 
 (CRO) 
Serious Adverse Event 
Size-Exclusion HPLC 
Standard Deviation 
Standard Operating Procedure 
Single-Photon Emission Computed Tomography 
Target to background ratio 
Thin Layer Chromatography 
Ultra Sounds 
Ultraviolet/Visible 
White Blood Cell 
Water For Injection 
World Health Organization 
Volumes Of Interest 
 
 

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3. Background and Rationale 
Atherosclerosis is projected to become an internationally leading cause of mortality1-3and is the 
underlying pathophysiology responsible for angina, myocardial infarction, transient ischemic 
attacks and stroke. Atherosclerosis is an inflammatory disease process that begins with the 
formation of lipid-rich fatty streaks in vascular endothelium, and eventually resulting in complexly 
remodeled plaques4 consisting of a central lipid rich and necrotic core bound by a thin fibrous 
cap5, 6. The fibrous cap is prone to eroding or rupturing leading to thrombus generation and 
resulting in severe ischemic injury of the tissue bed supplied by the thrombosed vessel7, 8. 
Rupture-prone plaque is referred to as vulnerable plaque9. 
 
Vascular inflammation can be imaged with 18-fluorodeoxyglucose positron emission tomography 
(FDG PET).FDG uptake imaged with PET is considered to be a marker of macrophage expression 
within plaque10. Macrophages are one of the main cellular components of inflamed atherosclerotic 
plaque11. However, a major limitation of FDG PET is the normal diffuse uptake in non-vascular 
structures (myocardium and neck musculature) that leads to poor specificity with false positive 
results. This extravascular uptake represents a challenge for imaging vasculature, particularly the 
coronaries and carotids12. Other cells adjacent to the target of interest and within the field of view 
may also take up FDG, resulting in difficulty with separating FDG uptake in inflamed lesions from 
surrounding tissues. 
 
Immunohistochemical examination of ruptured vulnerable plaques has demonstrated that there 
is increased expression of apoptotic and disintegrated macrophages within the lipid rich necrotic 
core13-15. In addition to macrophages, smooth muscle cells undergoing apoptosis or programmed 
cell death have been localized within the fibrous components of plaque16, 17. Further, expansion 
of the necrotic core may be related to plaque destabilization15, 18, 19. Thus, imaging apoptosis may 
identify vulnerable plaque and be a more specific imaging approach for advanced and 
complicated plaque than FDG PET. 
 
Apoptosis is an energy-dependent process of programmed cell death that ensues following the 
initiation of an internal and regulated suicide program20. A hallmark feature of apoptosis is the 
externalisation of phosphatidylserine (PS) as the cell transitions towards shrinkage, degradation 
of DNA and eventual fragmentation20. Annexin V is an endogenous human protein (molecular 
weight 36 kDalton) produced by epithelial cells. Annexin V binds with very high affinity to PS, and 
serves the purpose of labeling cells for phagocytosis21. Radiotracers that bind specifically to 
Annexin V have been developed for the non-invasive detection of apoptotic activity using imaging 
modalities such as SPECT. Early clinical cardiovascular studies with 99mTc labeled Annexin V and 
SPECT imaging demonstrated significant radiotracer uptake in 7 patients with acute myocardial 
infarction22 and in 4 patients with carotid artery atherosclerosis23. Validation studies in 
experimental rabbit models of atherosclerosis correlated uptake of 99mTc labeled Annexin V with 
histological degree of apoptosis, atherosclerotic lesion severity and macrophage burden24 and 
plaque vulnerability25. Thus, 99mTc labeled Annexin V has potential for imaging atherosclerotic 
lesions and identifying advanced lesions with greater apoptosis and vulnerability. 
99mTc-HYNIC-Annexin V was the early 99mTc labeled Annexin V used successfully in several 

A A A- A n n e xi n- 0 4 
 
P a g e 1 5 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
cli ni c al st u di e s b ut h a d a m aj or li mit ati o n wit h v er y hi g h r e n al u pt a k e r e s ulti n g i n a hi g h p ati e nt 
r a di ati o n d o s e a n d li miti n g a b d o mi n al i m a gi n g2 6 . A n o v el f or m of A n n e xi n- V wit h a n e n d o g e n o u s 
9 9 m T c c h el ati n g sit e (r h A n n e xi n V- 1 2 8) h a s b e e n d e v el o p e d 2 7 . 9 9 m T c l a b el e d r h A n n e xi n V- 1 2 8 h a s 
m or e r a pi d r e n al cl e ar a n c e t h a n 9 9 m T c- H Y NI C- A n n e xi n V a n d si mil ar d et e cti o n of a p o pt o si s i n 
a ni m al m o d e l s2 7 . 
 
9 9 m T c l a b el e d r h A n n e xi n V- 1 2 8 h a s b e e n e v al u at e d i n a P h a s e I cli ni c al tri al at t h e U ni v er sit y of 
Ott a w a H e ar t I n stit ut e i n 1 2 n or m al v ol u nt e er s. N o si g nifi c a nt a d v er s e eff e ct s w er e o b s er v e d. 
Bl o o d cl e ar a n c e w a s r a pi d. Gr e at e st r a di otr a c er u pt a k e w a s i n t h e ki d n e y s, bl a d d er ( d u e t o r a pi d 
ki d n e y cl e ar a n c e), li v er a n d l u n g s. T ot al eff e cti v e d o s e (I R C P 6 0) f or 9 9 m T c l a b el e d r h A n n e xi n V-
1 2 8 w a s 7. 7  + 0. 8 u S v/ M B q a n d w a s si g nifi c a ntl y l e s s t h a n 1 1. 0 + 0. 8 u S v/ M B q r e p ort e d f or 9 9 m T c-
H Y NI C- A n n e x i n V- 1 2 82 8 . 
 
Ultr a s o u n d i m a gi n g c a n pr o vi d e f urt h er i n si g ht i nt o t h e m or p h ol o g y of pl a q u e. B- m o d e ultr a s o u n d 
d eri v e d m e a s ur e s of pl a q u e e c h o g e ni cit y c a n pr e di ct t h e c o nt e nt of s oft li pi d ti s s u e a n d t h e 
a m o u nt of c al cifi c ati o n i n c ar oti d pl a q u e 2 9, 3 0 . E c h o g e ni c pl a q u e i s t y pi c all y c o m p o s e d of fi br o u s 
ti s s u e a n d c al cifi c ati o n, w hil e e c h ol u c e nt pl a q u e i s li pi d-ri c h 2 9, 3 0 . Pl a q u e 
m or p h ol o g y b y 
ultr a s o u n d 
h a s pr e di cti v e v al u e f or i d e ntif yi n g p ati e nt s at i n cr e a s e d ri s k of i s c h e mi c 
c er e br o v a s c ul ar e v e nt s i n d e p e n d e nt of d e gr e e of st e n o si s a n d v a s c ul ar ri s k f a ct or s 3 1 . A r e c e nt 
r e vi e w of ultr a s o u n d, c o m p ut e d t o m o gr a p h y a n d m a g n eti c r e s o n a n c e i m a gi n g of t h e c ar oti d 
art eri e s c o n cl u d e d t h at ultr a s o u n d w a s pr ef er a bl e at t h e pr e s e nt ti m e d u e t o hi g h s p ati al a n d 
t e m p or al r e s ol uti o n, s af et y, l o w c o st a n d wi d e a v ail a bilit y3 2 . 
 
T h e g o al of  t h e pr e s e nt i n v e sti g ati o n i s t o a s s e s s t h e f e a si bilit y of9 9 m T c-r h A n n e xi n V- 1 2 8 pl a n ar 
a n d S P E C T i m a gi n g a s a t e c h ni q u e f or d et e cti o n of a p o pt oti c c ar oti d pl a q u e i n a s y m pt o m ati c 
p ati e nt s wit h si g nifi c a nt c ar oti d art er y di s e a s e. T hi s i n v e sti g ati o n will d et er mi n e t h e pr e v al e n c e of 
si g nifi c a nt a p o pt oti c a cti vit y i n c ar oti d pl a q u e i n p ati e nt s wit h c ar oti d di s e a s e. 9 9 m T c-r h A n n e xi n V-
1 2 8 u pt a k e  i n t h e c ar oti d art eri e s a s a m e a s ur e of a p o pt oti c a cti vit y will b e c o m p ar e d t o pl a q u e 
ultr a s o u n d- b a s e d e c h o g e ni cit y a n d e c h ol u c e n c y, m e a s ur e s of pl a q u e v ul n er a bilit y. A orti c u pt a k e 
of 9 9 m T c-r h A n n e xi n V- 1 2 8 will b e i m a g e d a n d r el at e d t o c ar oti d u pt a k e of 9 9 m T c-r h A n n e xi n V- 1 2 8. 
 
4. 
St u d y O bj e cti v e s 
T h e pri m ar y o bj e cti v e of t hi s i n v e sti g ati o n i s: 
•  
T o d et er mi n e t h e f e a si bilit y of i m a gi n g a p o pt oti c a cti vit y i n c ar oti d at h er o s cl er oti c pl a q u e s 
of a s y m pt o m ati c or pr e vi o u s s y m pt o m ati c wit h TI A o nl y p ati e nt s wit h si g nifi c a nt c ar oti d 
art er y di s e a s e b y u si n g 9 9 m T c-r h A n n e xi n V- 1 2 8 i m a gi n g a n d t o r e p ort t h e pr e v al e n c e of 
a b n or m al 9 9 m T c-r h A n n e xi n V- 1 2 8 s c a n s. 
 
T h e s e c o n d ar y o bj e cti v e s ar e: 
•  
T o e st a bli s h t h e u pt a k e of 9 9 m T c-r h A n n e xi n V- 1 2 8 i n a c o ntr ol gr o u p of p arti ci p a nt s wit h 
n or m al c ar oti d ultr a s o u n d s. 
•  
T o a s s e s s t h e 9 9 m T c-r h A n n e xi n V- 1 2 8 u pt a k e v er s u s pl a q u e e c h o g e ni cit y a n d e c h ol u c e n c y. 
•  
T o m e a s ur e a orti c u pt a k e of 9 9 m T c-r h A n n e xi n V- 1 2 8 a n d a s s e s s t h e c orr el ati o n wit h it s 

A A A- A n n e xi n- 0 4 
 
P a g e 1 6 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
c ar oti d u pt a k e. 
 
5. H y p ot h e s e s 
5. 1 Pri m ar y H y p ot h e si s 
 
9 9 m T c-r h A n n e xi n V- 1 2 8 i m a gi n g c a n b e u s e d t o d et e ct a p o pt o si s i n c ar oti d pl a q u e i n a s y m pt o m ati c 
or pr e vi o u sl y s y m pt o m ati c wit h TI A o nl y p ati e nt s wit h at l e a st 5 0 % c ar oti d st e n o si s a s d efi n e d b y 
ultr a s o u n d. I n t hi s p o p ul ati o n, t h e a nti ci p at e d pr e v al e n c e of c ar oti d a p o pt o si s will b e 0. 3 t o 0. 5. 
 
5. 2 S e c o n d ar y H y p ot h e s e s 
 
•  
9 9 m T c-r h A n n e xi n V- 1 2 8 u pt a k e will b e i n cr e a s e d i n pl a q u e wit h gr e at er e c h o g e ni cit y 
•  
9 9 m T c-r h A n n e xi n V- 1 2 8 u pt a k e will b e d e cr e a s e d i n pl a q u e wit h gr e at er e c h ol u c e n c y 
•  
9 9 m T c-r h A n n e xi n V- 1 2 8 i m a gi n g c a n b e u s e d t o d et e ct a p o pt o si s i n t h e a ort a i n 
a s y m pt o m ati c p ati e nt s wit h at l e a st o n e 5 0 % c ar oti d st e n o si s a s d efi n e d b y ultr a s o u n d s. 
•  
A orti c u pt a k e of 9 9 m T c-r h A n n e xi n V- 1 2 8 will b e c orr el at e d wit h c ar oti d u pt a k e of 
9 9 m T c-
r h A n n e xi n V- 1 2 8 
 
6. St u d y D e si g n 
T hi s i s a si n gl e- c e ntr e, si n gl e d o s e, Pr o of of C o n c e pt ( P o C), P h a s e II st u d y. P arti ci p a nt s will 
r e c ei v e a si n gl e i ntr a v e n o u s b ol u s of 3 5 0 M B q ± 1 0 % of 9 9 mT c-r h A n n e xi n V- 1 2 8 f oll o w e d b y pl a n ar 
a n d S P E C T/ C T i m a gi n g of t h e c ar oti d s a n d a ort a s. C ar oti d pl a q u e e c h o g e ni cit y a n d e c h ol u c e n c y 
will b e a s s e s s e d b y c ar oti d ultr a s o u n d c arri e d o ut wit hi n 8 w e e k s of 
9 9 m T c-r h A n n e xi n V- 1 2 8 
i m a gi n g. Pl a n ar a n d S P E C T/ C T 9 9 m T c-r h A n n e xi n V- 1 2 8 c ar oti d i m a gi n g will b e o bt ai n e d i n 3 5 
a s y m pt o m ati c p arti ci p a nt s wit h at l e a st o n e > 5 0 % c ar oti d st e n o si s a n d i n 1 0 p arti ci p a nt s wit h 
n or m al c ar oti d ultr a s o u n d s. 
 
7. E n d of St u d y 
T h e e n d of t h e st u d y i s d efi n e d a s t h e c o m pl eti o n of all st u d y pr o c e d ur e s o n t h e l a st e nr oll e d 
p arti ci p a nt (i. e. l a st vi sit l a st p arti ci p a nt). 
 
8. St u d y P o p ul ati o n 
A p pr o v al f or t h e st u d y will b e o bt ai n e d fr o m t h e Ott a w a H o s pit al S ci e n c e N et w or k R e s e ar c h Et hi c s 
B o ar d ( O H S N- R E B) a n d H e alt h C a n a d a. All p arti ci p a nt s will pr o vi d e writt e n i nf or m e d c o n s e nt pri or 
t o t h e i niti ati o n of a n y st u d y pr o c e d ur e s. T hirt y-fi v e p arti ci p a nt s wit h c ar oti d st e n o si s a n d t e n a g e 
a n d s e x m at c h e d c o ntr ol p arti ci p a nt s will b e e nr oll e d. 
 
 
8. 1 I n cl u si o n crit eri a 
F or all p arti ci p a nt s: 

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1. Males and females age 18 years or greater; 
2. Able and willing to comply with the study procedures; 
3. Negative pregnancy test for women of childbearing potential at screening and on the day 
of administration of 99mTc-rhAnnexin V-128. 
 
For participants with carotid artery disease: 
4. Evidence of 50% or more carotid stenosis in one or more carotid arteries on carotid 
ultrasound within 10 years; 
 
For control participants: 
4. No significant carotid artery disease on carotid ultrasound; 
  
8.2 Exclusion criteria 
1. Previous carotid stenting or endarterectomy, or stroke; 
2. Diagnosis of vasculitis, dissection, or non-atherosclerotic carotid disease (Ehlers-Danlos, 
Marfans); 
3. Pregnancy or lactation; 
4. History of any disease or relevant physical or psychiatric condition or abnormal physical 
finding which may interfere with the study objectives at the investigator judgment; 
5. Know hypersensitivity to the investigational product or any of its components; 
6. Claustrophobia or inability to lie still in a supine position; 
7. Participation in another clinical trial within 4 weeks before study inclusion, except for 
patients who have participated or who are currently participating in a study without any 
study drug administration; 
8. Unwillingness to provide consent. 
 
8.3 Source of Study Population 
The carotid artery study population will be adult male and female patients who are referred to the 
outpatient cardiology clinics and/or the non-invasive Diagnostic Imaging Department at the 
University of Ottawa Heart Institute. The control population will be healthy volunteers who do not 
have carotid atherosclerosis as assessed by ultrasound and whose lab values are within the 
normal range. 
8.4 Participants Study Identification 
Each participant will be identified with a participant ID number. A unique participant identification 
number (Participant ID) will be assigned at the start of the screening period to each participant who 
signs the informed consent form. This number will identify the participant throughout the study. 
Participant IDs will include the 2-digit protocol number (04), the 2-letter code (CA) and a 3-digit 
participant number (ex: 04-CA001 for first participant in). 
8.5 Premature Discontinuation 
The withdrawal of a study participant is mandatory in the following cases: 

A A A- A n n e xi n- 0 4 
 
P a g e 1 8 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
•  
Pr e g n a n c y 
•  
Pr ot o c ol vi ol ati o n d et er mi n e d a s criti c al 
•  
L o st t o f oll o w- u p 
•  
S eri o u s i nt er- c urr e nt ill n e s s or ot h er s af et y r e a s o n s f or w h at t h e I n v e sti g at or c o n si d er s it 
i s i n t h e b e st i nt er e st of t h e p arti ci p a nt t o wit h dr a w fr o m t h e st u d y 
•  
S cr e e ni n g f ail ur e 
 
A “ s cr e e ni n g f ail ur e” i s a p arti ci p a nt w h o h a s si g n e d t h e i nf or m e d c o n s e nt, b ut w h o d o e s n ot m e et 
all s el e cti o n crit eri a f oll o wi n g t h e s cr e e ni n g e v al u ati o n s. F or p arti ci p a nt s n ot c o n si d er e d eli gi bl e 
aft er t h e s cr e e ni n g p eri o d, t h e r e a s o n f or n ot b ei n g eli gi bl e m u st b e d o c u m e nt e d. N o a d diti o n al 
a s s e s s m e nt s ar e n e e d e d. P arti ci p a nt i nf or m ati o n c oll e ct e d at t h e s cr e e ni n g vi sit will b e e nt er e d 
i n t h e e C R F a n d will b e u s e d i n t h e st u d y a n al y si s. 
 
T h e p arti ci p a nt s m a y wit h dr a w fr o m t h e st u d y if t h e y d e ci d e t o d o s o, at a n y ti m e a n d irr e s p e cti v e 
of t h e r e a s o n, or t hi s m a y b e t h e I n v e sti g at or’ s d e ci si o n. T h e pri m ar y r e a s o n f or a p arti ci p a nt’ s 
wit h dr a w al fr o m t h e st u d y s h o ul d b e d et er mi n e d if p o s si bl e. T h e d at e a n d r e a s o n f or 
di s c o nti n u ati o n will b e d o c u m e nt e d i n t h e e- C R F. 
 
8. 6 Pr o hi biti o n s a n d R e stri cti o n s 
T h e m o st i m p ort a nt r e q uir e d r e stri cti o n f or st u d y p arti ci p a nt s i s pr e g n a n c y. 
I m a gi n g i s p erf or m e d a m b ul at or y. Aft er i m a gi n g, p arti ci p a nt m a y g o b a c k h o m e or g o b a c k t o w or k 
wit h o ut a n y p arti c ul ar pr e c a uti o n s. 
A n y c o n c o mit a nt m e di c ati o n d e e m e d n e c e s s ar y f or t h e w elf ar e of t h e p arti ci p a nt d uri n g t h e st u d y 
m a y b e gi v e n at t h e di s cr eti o n of t h e I n v e sti g at or. H o w e v er, it i s t h e r e s p o n si bilit y of t h e I n v e sti g at or 
t o e n s ur e t h at d et ail s r e g ar di n g t h e m e di c ati o n ar e r e c or d e d i n f ull i n t h e c a s e r e p ort f or m, i n cl u di n g 
a n y c h a n g e s t h at h a v e o c c urr e d d uri n g t h e st u d y. 
 
9. I n v e sti g ati o n al Pr o d u ct, D o s e a n d M o d e of A d mi ni str ati o n 
 
T h e f ull n a m e of t h e I n v e sti g ati o n al Dr u g i s “ Kit f or t h e Pr e p ar ati o n of T c- 9 9 m R e c o m bi n a nt 
H u m a n A n n e xi n V- 1 2 8 f or I nj e cti o n”. 
 
9. 1 D e s cri pti o n of I n v e sti g ati o n al Pr o d u ct 
T h e kit will b e pr e p ar e d, p a c k a g e d a n d r el e a s e d a c c or di n g t o t h e m a n uf a ct ur er’ s St a n d ar d 
O p er ati n g Pr o c e d ur e s ( S O P s), a n d i n c o m pli a n c e wit h t h e pri n ci pl e s of t h e G o o d M a n uf a ct uri n g 
Pr a cti c e ( G M P) g ui d eli n e s, I C H G o o d Cli ni c al Pr a cti c e ( G C P) g ui d eli n e s, a n d a p pli c a bl e l o c al 
l a w s/r e g ul ati o n s. 
T h e i n v e sti g ati o n al pr o d u ct will b e s u p pli e d a s a st eril e, si n gl e vi al l y o p hili s e d kit f or r e c o n stit uti o n 
at t h e cli ni c al sit e wit h 9 9 m T c s ol uti o n el ut e d fr o m a g e n er at or.  
A si n gl e d o s e vi al c o nt ai n s 0. 4 m g of r h A n n e xi n V- 1 2 8. T h e kit c o nt ai n s al s o st a n n o u s c hl ori d e 
(r e d u ci n g a g e nt), s o di u m α - D- Gl u c o h e pt o n at e di h y dr at e (tr a n s c h el ati n g a g e nt), g e nti si c a ci d 
s o di u m s alt  h y dr at e (r a di ati o n st a bilit y e n h a n c er), h y dr o x y pr o p yl-β - c y cl o d e xtri n ( s ol u bili zi n g 

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agent), sodium metabisulfite (antioxidant) and trehalosedihydrate (lyoprotectant and cake forming 
agent). Lactic acid is also present as buffering agent. The kit composition details are included in 
the Appendix II. 
 
9.2 Handling, Preparation and Storage 
The investigational product must be stored, handled and administered only by qualified/authorized 
personnel and must be prepared in accordance with pharmaceutical quality requirements, and 
radiation safety regulations. 99mTc-rhAnnexin V-128 must be administered at the investigational 
site. Based on the stability tests performed (Appendix I), the Annexin Kit can be stored upon receipt 
at 5°C ± 3°C until the expiry date stated on the labels. 
 
A single dose vial containing 0.4 mg of lyophilized rhAnnexin V-128, will be reconstituted with 2 
mL ± 0.2 mL containing 740 MBq ± 74 MBq (20 mCi ± 2 mCi) of 99mTc eluted from the generator. 
Development studies have shown that this amount of radioactivity provides a sufficient amount of 
radioactivity for QC testing and the foreseen 99mTc rhAnnexin V-128 dose of 350 MBq up to 4 h 
after labeling. The administration volume (corresponding to 350 MBq) is calculated according to 
the estimated time of injection, on the basis of the physical decay of the radionuclide (half-life = 
6.02 h). Stability studies performed on the Drug Product have demonstrated radiochemical purity 
at 6 h from labeling greater than 90%, which is in line with current specifications of the Kit for the 
preparation of 99mTc-rhAnnexin V-128 for injection. For the purpose of this study, it is recommended 
to administer the reconstituted solution within 4 hours after completion of the radiolabeling. It is 
also required to determine the amount of radioactivity injected to the patient by measuring the 
radioactivity before and after injection with an appropriate radioactivity calibration system. 
 
The labeling reaction requires 90 minutes and the reconstituted radiolabeled product is stable for 
6 hours. Technetium-99m eluate should be obtained from an approved commercial Mo-99/Tc-99m 
generator that has been eluted within the past 24 hrs. The radiopharmacy will be directed to use 
the eluate within one hour of milking the generator. 
 
9.3 Investigational Product Accountability 
Drug inventory and accountability records for the “Kits for preparation of Technetium 99mTc-
rhAnnexin V-128 for injection” will be kept by the Investigator/radiopharmacist, and must be 
documented throughout the study. 
 
On an ongoing basis, the Investigator/radiopharmacist will conduct an investigational product (IP) 
supply inventory and to record the results of this inventory on the IP Accountability Record to 
reconcile delivery records with those of used and unused product. Any discrepancies must be 
accounted for. Appropriate forms of deliveries and returns must be signed by the person 
responsible for drug accountability. Used/unused “Kits for preparation of Technetium 99mTc-
rhAnnexin V-128 for injection” will be locally discarded. 
Refer to Appendix II for detailed instruction on the Radiolabeled Imaging Product 99mTc-rhAnnexin 
V-128, Cautionary notes, Analytical and Biological Controls, Stability and Shelf Life. 

A A A- A n n e xi n- 0 4 
 
P a g e 2 0 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
 
9. 4 I n v e sti g ati o n al Pr o d u ct D o s e, M o d e of A d mi ni str ati o n 
T h e " Kit f or pr e p ar ati o n of 9 9 m T c-r h A n n e xi n V- 1 2 8 f or i nj e cti o n" c o n si st s of 1 d o s e. 
 
P arti ci p a nt s will r e c ei v e o n e d o s e of 3 5 0 M B q ± 1 0 % of 9 9 m T c-r h A n n e xi n V- 1 2 8 a d mi ni st er e d a s a 
si n gl e i ntr a v e n o u s b ol u s. 
 
1 0.  
St u d y Pr o c e d ur e s 
V ol u nt ar y writt e n i nf or m e d c o n s e nt will b e o bt ai n e d pri or t o t h e i niti ati o n of a n y st u d y-r el at e d 
pr o c e d ur e s. St u d y c o n d u ct pr o c e d ur e s will i n cl u d e a s cr e e ni n g vi sit, t h e i m a gi n g st u di e s, a p h o n e 
vi sit wit hi n 2 4 h o ur p o st 9 9 m T c-r h A n n e xi n V- 1 2 8 a d mi ni str ati o n vi sit a n d a vi sit at 3 0 d a y s. 
 
1 0. 1  
B a s eli n e A s s e s s m e nt s 
•  E a c h p arti ci p a nt’ s d at e of birt h ( m m/ y y y y), g e n d er, et h ni cit y, w ei g ht, h ei g ht, m e di c al hi st or y, 
a n d r el e v a nt b a s eli n e c h ar a ct eri sti c s will b e r e c or d e d. 
•  R e s ult s fr o m a n y st a n d ar d of c ar e t e sti n g r el at e d t o t h e p arti ci p a nt’ s c o n diti o n will b e c oll e ct e d. 
•  W o m e n of c hil d b e ari n g p ot e nti al m u st h a v e n e g ati v e pr e g n a n c y t e st at s cr e e ni n g a n d b ef or e 
t h e i n v e sti g ati o n al pr o d u ct a d mi ni str ati o n. 
•  Li mit e d p h y si c al e x a m ( h ei g ht, w ei g ht, B MI) a n d vit al si g n s ( s y st oli c a n d di a st oli c bl o o d 
pr e s s ur e, h e art r at e), will b e r e c or d e d. 
 
1 0. 2  
L a b or at or y A s s e s s m e nt s 
Bl o o d s a m pl e s f or h e m at ol o g y, bi o c h e mi str y a n d uri n al y si s will b e o bt ai n e d at b a s eli n e f or 
s cr e e ni n g, 3 0 +/- 3 d a y s p o st I P a d mi ni str ati o n a n d f oll o wi n g a n y a d v er s e e v e nt s. 
 
I n c a s e of cli ni c all y si g nifi c a nt a b n or m aliti e s i n b a s eli n e l a b or at or y v al u e s, t h e p arti ci p a nt will b e 
d e cl ar e d a s a s cr e e ni n g f ail ur e. 
 
 
 

A A A- A n n e xi n- 0 4 
 
P a g e 2 1 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
 
H e m at ol o g y  
C o a g ul ati o n  
Bl o o d C h e mi str y  
Uri n al y si s 
•  
W B C wit h 
diff er e nti al  
•  
R B C  
•  
Pl at el et s 
•  
H b 
•  
M C V 
•  
H e m at o crit 
•  P T 
•  P T T 
•  I N R 
•  B U N 
•  Uri c a ci d 
•  Al b u mi n 
•  Dir e ct bilir u bi n 
•  L D H 
•  C al ci u m 
•  C hl ori d e 
•  P h o s p h or u s 
•  T ot al c h ol e st er ol 
•  T ot al pr ot ei n 
•  S er u m cr e ati ni n e 
•  T ot al bilir u bi n 
•  A P 
•  A S T/ A S A T 
•  A L T/ A L A T 
•  G a m m a- G T 
•  S o di u m 
•  P ot a s si u m 
•  Gl u c o s e 
•  ß- H C G at s cr e e ni n g  
• 
Di p sti c k t e st1  
• 
Pr e g n a n c y te st  
( b ef or e i nj e cti o n of 
st u d y pr o d u ct, if 
a p pli c a bl e)  
 
 
1 I n c a s e o n e of t h e a s s e s s m e nt s of t h e di p sti c k t e st i s p o siti v e, a mi cr o s c o pi c a n al y si s of t h e uri n e 
m u st b e p erf or m e d. 
 
L a b or at or y 
A s s e s s m e nt s 
will b e p erf or m e d b y t h e 
 
 T h e Ott a w a H o s pit al a c c or di n g t o Mi ni str y of H e alt h a n d L o n g T er m C ar e 
( M H L T C) st a n d ar d s. 
 
1 0. 3 
9 9 m T c-r h A n n e xi n V- 1 2 8 Pl a n ar a n d S P E C T I m a gi n g of t h e C ar oti d Art eri e s a n d 
A ort a a n d I m a g e A n al y si s 
Pl a n ar a n d S P E C T i m a gi n g of t h e c ar oti d s a n d a ort a will b e p erf or m e d 6 0 a n d 1 2 0 mi n ut e s aft er 
i nj e cti o n of tr a c er. 
A d mi ni str ati o n of t h e 9 9 m T c-r h A n n e xi n V- 1 2 8 ( 3 5 0 M B q ± 1 0 %) will b e a s a si n gl e b ol u s vi a a n 
i ntr a v e n o u s c at h et er i n a n a nt e c u bit al v ei n f oll o w e d b y a s ali n e fl u s h. N e g ati v e pr e g n a n c y t e st f or 
w o m e n of c hil d b e ari n g p ot e nti al will b e c o nfir m e d o n t h e d a y of a d mi ni str ati o n. 
All i m a g e s will b e a c q uir e d wit h a d u al h e a d S P E C T/ C T g a m m a c a m er a wit h l o w- e n er g y hi g h-
r e s ol uti o n c olli m at or s. T h e e n er g y a c c e pt a n c e wi n d o w f or t h e 9 9 mT c p h ot o p e a k will b e 1 4 0 k e V ( +/- 
1 0 %). A l o w d o s e C T s c a n ( h eli c al, 1 2 0 k V p, 1 m A wit h 1. 9 pit c h) will b e a c q uir e d of t h e n e c k, 
t h or a x a n d a b d o m e n f or att e n u ati o n c orr e cti o n. 

AAA-Annexin-04 
 
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Reconstruction will be done using iterative reconstruction incorporating CT-based attenuation 
correction and dual-energy-window scatter correction. Planar and SPECT images of the carotid 
arteries and thoracic and abdominal aorta will be acquired at 1 and 2 hours post-injection. Acquired 
images will be stored for off-line analysis using a Hermes Gold workstation (Hermes Medical 
Solutions). Volumes-of–interest (VOIs) will be placed over the carotids and the thoracic and 
abdominal aortic sections to determine image counts from the attenuation and scatter corrected 
images. A99mTc source of known activity will be imaged and used to determine the imaging system 
calibration factor for converting reconstructed image counts into an activity concentration (MBq/cc 
or % injected dose/gram). 
 
A normal database of carotid and aortic uptake will be determined from 10 control participants and 
used to identify abnormal uptake in carotid artery disease participants. 
 
Inter and intra-observer variability will be determined by repeated analysis of the images of 20 
participants. Two observers will carry out the assessment of inter-observer variability.  Images will 
be anonymized prior to analysis and observers will be blinded to all clinical data.  
 
10.4 
99mTc-rhAnnexin V-128 Radiation Risk Assessment 
Participants will receive radiation from 1) 99mTc-rhAnnexin V-128 (350 MBq) for a dose of 2.2 mSv 
(7.7 + 0.8 uSv/MBq) and 2) the CT scan for attenuation correction for a dose of 1.8 mSv. Total 
dose for 99mTc-rhAnnexin V-128 and CT components will be 4.0 mSv. 
 
10.5 
Ultrasound Examination 
Clinical evidence of 50% or more carotid stenosis in one or more carotid arteries on carotid 
ultrasound within 10 years prior to enrolment is required for inclusion in the trial.   
Evidence of 50% or more carotid stenosis has to be confirmed in a more recent US imaging within 
8 weeks prior to 99mTc-rhAnnexin V-128 administration.  If not confirmed, the participant will be 
declared as a screening failure. 
 
B-mode and color Doppler ultrasound studies will be acquired of both carotid arteries and 
performed with an ultrasound scanner equipped with a 5- to 7-MHz transducer. Plaque 
morphology, as echogenicity, defined as reflectance of the emitted ultrasound signal, will be 
assessed as previously described29 and graded from 1 to 4 as echolucent, predominantly 
echolucent, predominantly echogenic, or echogenic. The vessel lumen will be used as the 
reference structure for defining echolucency, and the bright echo zone produced by the media-
adventitia interface in the far wall will be used as the reference structure for defining echogenicity. 
Interobserver reproducibility of plaque morphology in stenotic arteries has been previously 
assessed (=0.56, 95% CI 0.38 to 0.74)31. 
 
The degree of stenosis will be calculated by the following equation: (1−PSVr/PSVs)×100%, where 
PSVr denotes peak systolic velocity at the point of reference (here, the distal carotid artery) and 
PSVs the peak systolic velocity in the stenosis31. 

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11. 
Data Monitoring Committee 
The Data Monitoring Committee (DMC) consists of investigators and Sponsor representatives, as 
well as external persons such as independent experts, if deemed necessary by the Sponsor. The 
DMC will review and evaluate the images of the first 15 patients and the first 5 healthy participants 
in terms of image quality, carotid target uptake and clinical relevance of the study product. The 
DMC will also review the safety data.  The frequency of abnormal carotid scans will be determined 
in the participant and normal groups.  The study will be terminated if there is a low frequency of 
positive scans in the carotid participant group or high frequency of positive scans in the normal 
group. 
 
The DMC will promptly give recommendations to continue or terminate the study. The DMC report 
will be prepared by the Sponsor and sent to the REB and regulatory authorities as required.  
Preliminary results can be used by the Sponsor for publication purpose, before the end of the main 
trial. 
 
12. 
Statistical methods 
12.1 
Sample size and analysis 
The primary hypothesis is that 99mTc-rhAnnexin V-128 SPECT carotid imaging can detect 
apoptosis. We anticipate that the prevalence of positive 99mTc-rhAnnexin V-128 SPECT carotid 
scans will be about 0.3 to 0.5 of the patients. A sample size of 30 patients produces a 95% 
confidence interval with a precision of about 0.17 to 0.20 when the estimated proportion is 0.3 to 
0.5. Sample size was also estimated for the comparison of 99mTc-rh-Annexin-V 128 uptake in 
asymptomatic patients with carotid disease versus normals using a 5% significance level and 
power of 95%. The measured neck uptake in 12 normals was 0.8 + 0.27% ID/gm in the Phase I 
study. Assuming a similar SD of 0.27% ID/gm in the patients and a minimal clinically important 
difference (MCID) of 50% or a change of 0.4 in uptake, the required sample size is 9 normals and 
25 patients. Allowing for attrition, we plan to recruit 10 normals and 35 patients. 
 
12.2 
General statistical considerations 
Statistical methods will be detailed in the Sponsor statistical analysis plan. 
 
Continuous variables will be presented as number of non-missing values, mean, standard 
deviation, median, minimum, maximum and quartiles. For categorical variables, descriptive 
statistics will include counts and percentages per category. Confidence intervals will be computed 
when appropriate. Continuous variables will be compared using the most appropriate test such as 
paired analysis Mann-Whitney-Wilcoxon U test or paired analysis student-t test. Proportions will 
be compared using the most appropriate test such as Chi squared test, fisher exact test or 
McNemar test. Pearson’s or Spearman linear regression analysis will be used to calculate the 
relationship between two data sets as appropriate. A p value less or equal to 0.05 will be 
considered significant. 
 

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No adjustment for multiplicity will be applied and missing data will not be replaced. 
 
12.3 
Demographics and Other Participant Characteristics 
Demographic and other baseline data will be summarized descriptively. All background and 
demographic data will be listed in detail. 
 
12.4 
Efficacy 
Primary endpoint of PoC: 
The feasibility of imaging apoptotic activity in carotid atherosclerotic plaques using 99mTc-rhAnnexin 
V-128 will be determined by the data monitoring committee (visual image review and consensus). 
 
Primary endpoint of Phase II: 
Efficacy of 99mTc-rhAnnexin V-128 planar and SPECT/CT imaging will also be evaluated by 
determining the prevalence of abnormal 99mTc-rhAnnexin V-128 scans. 
 
Secondary endpoints: 
Descriptive statistics of 99mTc-rhAnnexin V-128 uptake in control subjects will be presented by 
areas of interest to assess the background uptake profile. 
99mTc-rhAnnexin V-128 uptake will be related to ultrasound data of plaque echogenicity and 
echolucency, by direct comparison and by using correlation test and/or diagnostic test 
performance methods (McNemar test) if appropriate. 
99mTc-rhAnnexin V-128 uptake in carotids will be correlated to its aortic uptake in all participants. 
 
Efficacy analysis of the primary endpoint will be mainly descriptive in nature. Inferential statistics 
(such as comparisons, correlations…) will be mainly conducted as explorative analyses to serve 
as the basis for future confirmatory trials. 
 
12.5 
Safety 
The statistical analysis of safety data will be mainly descriptive in nature. 
12.5.1 Adverse Events / Serious Adverse Events 
All original AE/SAE terms will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA). System organ classes and preferred terms will be used in the analyses. The type and 
incidence of AEs/SAEs, as well as severity and relatedness to the investigational product will be 
tabulated. 
 
12.5.2 Laboratory Tests 
Descriptive statistics including shift tables will be generated for all laboratory tests performed i.e. 
the actual values and the changes from pre-injection by cross tabulations (with classes for below, 
within, and above normal range). 
Laboratory data will be analysed with respect to the normal ranges of values provided by the local 

A A A- A n n e xi n- 0 4 
 
P a g e 2 5 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
l a b or at or y a n d wit h r e s p e ct t o l e v el s of c h a n g e a n d si g nifi c a n c e i n t h e s e v al u e s. A b n or m al 
l a b or at or y t e st r e s ult s will b e t a b ul at e d. 
1 3.  
A d v er s e E v e nt s a n d ot h er S af et y A s p e ct s 
1 3. 1  
D efi niti o n of A d v er s e E v e nt s 
A n A E i s d e fi n e d a s a n y u nt o w ar d m e di c al o c c urr e n c e i n a p arti ci p a nt a n d w hi c h d o e s n ot 
n e c e s s aril y h a v e a c a u s al r el ati o n s hi p wit h t h e i n v e sti g ati o n al pr o d u ct. A n A E c a n t h er ef or e b e a n y 
u nf a v o ur a bl e a n d u ni nt e n d e d si g n (i n cl u di n g a n a b n or m al l a b or at or y fi n di n g), s y m pt o m, or 
di s e a s e, t e m p or all y a s s o ci at e d wit h t h e u s e of a n i n v e sti g ati o n al pr o d u ct, w h et h er or n ot c a u s all y 
r el at e d t o t h e i n v e sti g ati o n al pr o d u ct. 
A E s will b e r e p ort e d, if a p pli c a bl e, fr o m t h e si g ni n g of t h e i nf or m e d c o n s e nt u ntil t h e l a st st u d y-
r el at e d pr o c e d ur e. 
1 3. 2  
D efi niti o n of S eri o u s A d v er s e E v e nt s 
A S A E i s a n y u nt o w ar d m e di c al o c c urr e n c e t h at at a n y d o s e: 
•  
R e s ult s i n d e at h; 
•  
I s lif e-t hr e at e ni n g; 
N ot e: “lif e -t hr e at e ni n g” r ef er s t o a n e v e nt i n w hi c h t h e p arti ci p a nt i s at ri s k of d e at h at t h e 
ti m e of t h e e v e nt; it d o e s n ot r ef er t o a n e v e nt w hi c h h y p ot h eti c all y mi g ht h a v e c a u s e d 
d e at h if it w a s m or e s e v er e; 
•  
R e s ult s i n p er si st e nt or si g nifi c a nt di s a bilit y or i n c a p a cit y; 
•  
R e s ult s i n c o n g e nit al a n o m al y or birt h d ef e ct; 
•  
R e q uir e s i n p ati e nt h o s pit ali z ati o n or pr ol o n g ati o n of h o s pit ali z ati o n. 
S eri o u s A d v er s e E v e nt s ( S A E) will b e d efi n e d a n d r e p ort e d a c c or di n g t o I C H/ G C P a n d R e g ul at or y 
St a n d ar d s. S A E s will b e r e p ort e d fr o m t h e si g ni n g of t h e i nf or m e d c o n s e nt a n d f oll o w e d u ntil 
r e s ol uti o n or d et er mi n e d t o b e n ot cli ni c all y si g nifi c a nt. 
 
1 3. 3  
Pr o c e d ur e i n C a s e of Pr e g n a n c y 
Pri or t o cli ni c al st u d y e nr ol m e nt, w o m e n of c hil d b e ari n g p ot e nti al 
m u st b e a d vi s e d of t h e 
i m p ort a n c e of a v oi di n g pr e g n a n c y d uri n g cli ni c al st u d y p arti ci p ati o n a n d t h e p ot e nti al ri s k s f or a n 
u ni nt e nti o n al pr e g n a n c y. D uri n g t h e cli ni c al st u d y, all w o m e n of c hil d b e ari n g p ot e nti al s h o ul d u s e 
of a r eli a bl e 
m e a n s of c o ntr a c e pti o n, a n d s h o ul d b e i n str u ct e d t o c o nt a ct t h e I n v e sti g at or 
i m m e di at el y if t h e y s u s p e ct t h e y mi g ht b e pr e g n a nt ( e. g. mi s s e d or l at e m e n str u al p eri o d). 
T h e I n v e sti g at or m u st r e p ort t o t h e S p o n s or a n y pr e g n a n c y a s s o ci at e d wit h i n v e sti g ati o n al 
pr o d u ct e x p o s ur e i n cl u di n g c o n c e pti o n s o c c urri n g u ntil 3 0 d a y s aft er t h e I P a d mi ni str ati o n. 
A p pr o pri at e pr e g n a n c y f oll o w- u p pr o c e d ur e s will b e c o n si d er e d if i n di c at e d. T h e I n v e sti g at or 
s h o ul d r e s p o n d i n a c c or d a n c e wit h t h e r e p orti n g pr o c e d ur e f or S A E s i n cl u di n g i nf or m ati o n 
r e g ar di n g t h e o ut c o m e of pr e g n a n c y. 
1 3. 4  
N e w S af et y I nf or m ati o n Aff e cti n g t h e C o n d u ct of t h e St u d y 
A n y i nf or m ati o n or c h a n g e s si g nifi c a ntl y aff e cti n g t h e c o n d u ct of t h e tri al a n d/ or i n cr e a si n g t h e 
ri s k t o p arti ci p a nt s will b e pr o vi d e d t o all i n v e sti g at or s, t h e R E B, a n d R e g ul at or y A ut h oriti e s. 

A A A- A n n e xi n- 0 4 
 
P a g e 2 6 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
D e p e n di n g o n t h e n at ur e of t h e i nf or m ati o n or t h e c h a n g e s, t h e pr ot o c ol a n d/ or t h e p arti ci p a nt 
i nf or m ati o n m a y n e c e s sit at e a n a m e n d m e nt. 
 
1 3. 5  
D at a M o nit ori n g a n d S af et y 
T h e d at a c oll e ct e d f or t hi s st u d y i s o b s er v ati o n al i n d e si g n a n d will n ot b e u s e d f or cli ni c al c ar e or 
cli ni c al d e ci si o n m a ki n g. N o f or m al D S M B will b e f or m e d. H o w e v er, t h e s af et y d at a will b e p art of 
t h e r e vi e w a n d a s s e s s m e nt b y t h e D M C. 
1 4.  
T er mi n ati o n of t h e st u d y 
E arl y t er mi n ati o n of t h e st u d y c a n o c c ur i n t h e f oll o wi n g c a s e s: 
 
•  
W h e n t h e vi s u al r e vi e w a n d a n al y si s of t h e i m a g e s of t h e fir st 1 5 p ati e nt s a n d 5 n or m al s 
b y t h e D at a M o nit ori n g C o m mitt e e d o e s n ot d e m o n str at e t h e di a g n o sti c p ot e nti al of t h e 
st u d y pr o d u ct i n t er m s of q u alit y or effi c a c y, t h e S p o n s or m a y di s c o nti n u e t h e cli ni c al st u d y 
b y s e n di n g a writt e n n oti c e t o t h e i n v e sti g at or a n d c o m p et e nt a ut h oriti e s. 
•  
W h e n t h e S p o n s or i s a w ar e of n e w i nf or m ati o n o n m att er s c o n c er ni n g t h e s af et y of t h e 
st u d y pr o d u ct, a s w ell a s ot h er i m p ort a nt i nf or m ati o n t h at m a y aff e ct pr o p er c o n d u ct of t h e 
cli ni c al st u d y, t h e S p o n s or m a y di s c o nti n u e t h e cli ni c al st u d y a n d s e n d a writt e n n oti c e of 
t h e di s c o nti n u ati o n t o t h e i n v e sti g at or a n d c o m p et e nt a ut h oriti e s. 
•  
If t h e i n v e sti g at or i nt e n d s t o di s c o nti n u e p arti ci p ati o n i n t h e st u d y, t h e i n v e sti g at or m u st 
i m m e di at el y i nf or m t h e S p o n s or wit h writt e n n oti c e a b o ut t h e di s c o nti n u ati o n a n d t h e 
r e a s o n f or it. 
•  
T h e st u d y i s st o p p e d b y a r e g ul at or y a ut h orit y. 
•  
T h e S p o n s or r e s er v e s t h e ri g ht t o di s c o nti n u e t h e st u d y at a n y ti m e f or a n y r e a s o n b y 
s e n di n g a writt e n n oti c e of t h e di s c o nti n u ati o n t o t h e i n v e sti g at or a n d c o m p et e nt 
a ut h oriti e s. 
1 5.  
O p er ati o n al, Et hi c al a n d A d mi ni str ati v e C o n si d er ati o n s 
1 5. 1  
Cli ni c al St u d y M o nit ori n g a n d A u dit 
P eri o di c s tu d y m o nit ori n g will b e c o n d u ct e d b y A A A t o e n s ur e t h at p arti ci p a nt s’ h u m a n ri g ht s, 
s af et y, a n d w ell- b ei n g ar e pr ot e ct e d, t h at t h e st u d y i s pr o p erl y c o n d u ct e d i n a d h er e n c e t o t h e 
c urr e nt pr ot o c ol a n d t h e pri n ci pl e s of I C H G C P a s w ell a s D e cl ar ati o n of H el si n ki, a n d t h at t h e 
d at a r e p ort e d b y t h e I n v e sti g at or or d e si g n e e ar e a c c ur at e, c o m pl et e, a n d v erifi a bl e wit h t h e 
s o ur c e d o c u m e nt s. T h e a s si g n e d Cli ni c al St u d y M o nit or( s) will m o nit or t h e st u d y i n a c c or d a n c e 
wit h t h e m o nit ori n g g ui d eli n e s. A c o p y of t h e M o nit ori n g L o g will b e r etri e v e d f or t h e tri al m a st er 
fil e at t h e st u d y cl o s e- o ut vi sit s. T h e d e si g n at e d m o nit or will h a v e t h e tr ai ni n g a n d q u alifi c ati o n s 
n e c e s s ar y t o pr o vi d e a n a p pr o pri at e a n d t h or o u g h v erifi c ati o n of t h e st u d y fil e s.  D uri n g t h e st u d y, 
t h e I n v e sti g at or will p er mit t h e St u d y M o nit or t o v erif y t h e pr o gr e s s of t h e st u d y at t h e c e ntr e a s 
fr e q u e ntl y a s n e c e s s ar y. T h e I n v e sti g at or will m a k e t h e el e ctr o ni c d at a s cr e e n s a v ail a bl e, pr o vi d e 
mi s si n g or c orr e ct e d d at a, a n d si g n t h e e- C R F. K e y d at a tr a n s cri b e d i nt o t h e e- C R F will b e 
r e vi e w e d a g ai n st t h e s o ur c e d o c u m e nt s. P er s o n al i nf or m ati o n 
will b e tr e at e d a s stri ctl y 
c o nfi d e nti al a n d will n ot b e m a d e p u bli cl y a v ail a bl e. A n y i n c o n si st e n c y b et w e e n t h e s o ur c e d at a 
a n d t h e d at a r e c or d e d i n t h e e- C R F will b e c orr e ct e d. 

A A A- A n n e xi n- 0 4 
 
P a g e 2 7 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V er si o n 5. 0, 2 F e br u ar y 2 0 1 8 
 
T h e S p o n s or will e n s ur e t h at a p pr o pri at e Q u alit y C o ntr ol ( Q C) st e p s ar e i n cl u d e d i nt o t h e diff er e nt 
cli ni c al pr o c e s s e s t o g u ar a nt e e a d e q u at e pr ot e cti o n of t h e st u d y p arti ci p a nt s a n d q u alit y of t h e 
d at a. 
T h e I n v e sti g at or i s r e s p o n si bl e f or t h e a c c ur a c y of t h e d at a e nt er e d o n t h e e- C R F s. T h e r el e v a nt 
p a g e s of e a c h e- C R F s h o ul d b e f ull y c o m pl et e d wit hi n 5 w or ki n g d a y s of t h e p arti ci p a nt’ s vi sit t o 
w hi c h t h e d at a r el at e, t o all o w t h e Cli ni c al R e s e ar c h A s s o ci at e s ( C R A s) t o r e vi e w t h e s e p a g e s 
pr o m ptl y. S uffi ci e nt r e s o ur c e s m u st b e a v ail a bl e t o pr o m pt e- C R F c o m pl eti o n a n d c oll e cti o n. 
R e q u e st f or cl arifi c ati o n s t o d at a ( d at a q u eri e s) s h o ul d b e a d dr e s s e d wit hi n 5 w or ki n g d a y s of 
r e c ei pt. 
 
T h e I n v e sti g at or s h all all o w d e si g n at e d C R O/ S p o n s or r e pr e s e nt ati v e s, r e pr e s e nt ati v e s of t h e 
R E B a n d r e g ul at or y b o di e s dir e ct a c c e s s t o t h e s o ur c e d o c u m e nt s ( p a p er or el e ctr o ni c) t o v erif y 
t h e d at a r e p ort e d i n t h e e- C R F s a n d d at a q u eri e s ( s o ur c e d o c u m e nt s ar e t h e ori gi n al s of a n y 
d o c u m e nt s u s e d b y t h e I n v e sti g at or or h o s pit al/i n stit uti o n t h at all o w v erifi c ati o n of t h e e xi st e n c e 
of t h e s u bj e ct a n d s u b st a nti at e t h e i nt e grit y of t h e d at a c oll e ct e d d uri n g t h e tri al). S o ur c e 
d o c u m e nt s s h o ul d b e a v ail a bl e t o s u p p ort all t h e d at a r e c or d e d i n t h e e- C R F, u nl e s s ot h er wi s e 
s p e cifi e d i n t h e e- C R F a n d d at a q u eri e s. 
 
T h e R e g ul at or y A ut h oriti e s a n d/ or t h e Ott a w a H o s pit al S ci e n c e N et w or k R e s e ar c h Et hi c s B o ar d 
( O H S N- R E B) m a y r e vi e w t hi s st u d y. T hi s i m pli e s t h at a u dit or s/i n s p e ct or s h a v e t h e ri g ht t o i n s p e ct 
t h e st u d y c e ntr e( s) at a n y ti m e d uri n g a n d/ or aft er c o m pl eti o n of t h e st u d y a n d h a v e a c c e s s t o 
s o ur c e d o c u m e nt s, i n cl u di n g t h e p arti ci p a nt’ s fil e. 
 
St u d y D o c u m e nt s 
S o ur c e d at a m u st b e m ai nt ai n e d at t h e st u d y c e ntr e t o d o c u m e nt t h e e xi st e n c e of t h e st u d y 
p arti ci p a nt s a n d s u b st a nti at e t h e i nt e grit y of t h e c oll e ct e d st u d y d at a. T h e a ut h or of a n e ntr y i n 
t h e s o ur c e d o c u m e nt s m u st b e i d e ntifi a bl e. 
T h e s o ur c e d o c u m e nt s s h o ul d at l e a st i n cl u d e t h e f oll o wi n g i nf or m ati o n f or e a c h p arti ci p a nt: 
•  
P arti ci p a nt i d e ntifi c ati o n; 
•  
D o c u m e nt ati o n of eli gi bilit y crit eri a; 
•  
C o n s e nt pr o c e s s, si g n e d a n d d at e d I C F; 
•  
D at e s of all vi sit s, st u d y pr o c e d ur e s d o c u m e nt ati o n; 
•  
I m a g e s/ s c a n s; 
•  
I n v e sti g ati o n al pr o d u ct a d mi ni str ati o n ti m e a n d d at e; 
•  
R e c ei pt, di s p e n s ati o n a n d d e str u cti o n of u s e d/ u n u s e d i n v e sti g ati o n al pr o d u ct; 
•  
R e c or d of all A E s, S A E s a n d ot h er s af et y p ar a m et er s; 
•  
D at e of st u d y c o m pl eti o n or r e a s o n f or e arl y di s c o nti n u ati o n (if a p pli c a bl e). 
1 5. 2 
Et hi c s  a n d Pr ot e cti o n of P arti ci p a nt C o nfi d e nti alit y 
1 5. 2. 1 Et hi c al C o n d u ct of Cli ni c al St u d y 
T h e I n v e sti g at or( s) a n d all p arti e s i n v ol v e d i n t hi s st u d y will c o n d u ct t h e st u d y i n a d h er e n c e t o t h e 
et hi c al pri n ci pl e s b a s e d o n t h e D e cl ar ati o n of H el si n ki, G C P, I C H g ui d eli n e s, a n d t h e a p pli c a bl e 

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laws and regulations. 
 
ICH-GCP is an international ethical and scientific quality standard for designing, conducting, 
recording, and reporting study activities that involve the participation of human participants. 
Compliance with this standard provides public assurance that the rights, safety, and well-being of 
the participants are protected, consistent with the principles that have their origin in the 
Declaration of Helsinki, and that the study data are credible. 
 
The Investigator and all study staff will conduct the study in compliance with the REB and 
regulatory approved version of this protocol. The protocol, ICF, any information provided to the 
participant as well as any recruitment advertisements (if applicable), and any amendments to 
these items will have REB approval prior to their use in the study. Voluntary informed consent will 
be given by every participant in order to participate in the study-related procedures. The rights, 
safety, and well-being of the participants are the most important considerations and prevail over 
the interests of science and society. All personnel involved in the conduct of this study must be 
qualified by education, training, and experience to perform their assigned responsibilities. 
 
15.2.2 Authorities 
The protocol, name, and study centre of the Investigators, as well as other required documents 
will be submitted to Health Canada ( Regulatory Authority), the Ottawa Hospital Science Network 
Research Ethics Board and the Ottawa Heart Institute Research Corporation according to 
requirements for review and approval before the beginning of the study. The Authorities will be 
informed about the end of the study and the results of the study in a way that guarantee 
confidentiality and Sponsor’s rights in terms of intellectual and/or industrial property. 
 
15.3 
Arrangement for Use of Information and Publication of Clinical Study Data 
All information regarding the investigational product under study in the outlined protocol and the 
manufacturer’s operations, such as, but not limited to, patent applications, formulas, 
manufacturing processes, scientific data, or formulation information, supplied by the manufacturer 
and not previously published, are considered confidential and shall remain the sole property of 
the investigational product manufacturer. The Investigator agrees to use this information only to 
perform this study and will not use it for other purposes including publications and presentations 
without the investigational product manufacturer’s explicit written consent. 
 
It is understood by the Investigator that the information developed during the conduct of this study 
including but not limited to study data and results is considered confidential and the sole property 
of the Sponsor, and will be used by the investigational product manufacturer for the development 
of the specified investigational medication and may be disclosed as deemed necessary by the 
investigational product manufacturer to other Investigators, other pharmaceutical companies, and 
to governmental agencies. 
 
The Investigator agrees that before he/she publishes any results or data of this study, he/she shall 
send the draft manuscripts and copies of the information to be presented to the investigational 

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product manufacturer at least 30 working days before submission to a publisher or presentation. 
The investigational product manufacturer reserves the right to review these materials before 
submission for publication or presentation. This is not intended to restrict or hinder publication or 
presentation but instead to allow the investigational product manufacturer to protect proprietary 
information and to provide comments based on information that may not yet be available to the 
Investigator(s). 
 
15.4 
Records Related to the Clinical Study and Confidentiality 
The Investigator must retain e-CRFs and source documents of all enrolled participants (i.e. all 
participants who gave consent to be screened for the study), investigational product disposition, 
and other documents required by regulation, in his/her possession or in an accessible area for at 
least 25 years after the completion of this study. 
 
Individual nominative participant medical information obtained as a result of this study is 
considered confidential and disclosure to third parties is prohibited. Such information may only be 
given to a third party after approval of the participant, such as to the participant’s general 
practitioner or to other appropriate medical personnel responsible for the participant’s well-being. 
 
All individuals and organizations involved in conducting the study and/or processing the study 
data will protect the participants’ privacy with appropriate measures in accordance with the 
applicable local and regional laws. 
 
15.5 
Protocol Amendment and/or Revision and Protocol Deviations 
Any deviation from the protocol that has not been approved by the Sponsor or designee and by 
the REB/regulatory authorities may result in the discontinuation from the trial of the site involved. 
However, in the event of any medical emergency, the Investigator is free to perform any medical 
procedure deemed appropriate. Such events and procedures must be reported promptly to the 
Sponsor. 
 
Any changes to the study, which arise after approval of the protocol, will be documented as 
protocol amendments and/or revisions. Depending on the nature of the amendment and/or 
revision, REB/ Regulatory Authority approval or notification is required. The changes will become 
effective only after the approval of the REB/Regulatory Authority (if applicable). 
 
15.6 
Qualification of the Investigators and delegation of responsibility 
The Investigator(s) should be qualified by education, training, and experience to assume 
responsibility for the proper conduct of the study. He/she should meet all qualifications specified 
by the applicable regulatory requirements and should provide evidence of such qualifications 
through an up-to-date curriculum vitae (Principal as well as all other Investigators) and/or other 
relevant documentation requested. 
 
The Investigator should be thoroughly familiar with the appropriate use of the investigational 

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product, as described in the protocol, the current Investigator’s Brochure, the product information, 
and other information sources provided by the investigational product manufacturer. 
The Investigator should be aware of, and should comply with, ICH-GCP and the applicable 
regulatory requirements. 
 
The Investigator should maintain a list of appropriately qualified persons to whom the Investigator 
has delegated significant study related duties. 
 
15.7 
Conflict of Interest and Financial Disclosure 
There are no conflicts of interest to declare related to this study. The Principal Investigator is 
receiving financial support and the investigational product from the manufacturer to cover the cost 
of conducting this study. 
 
Disclosable financial interests will be recorded on the Investigator Financial Disclosure Form. 
 
Any Investigator(s) added as investigational staff must complete the Investigator Financial 
Disclosure Form at the beginning of his/her participation to the study. For any Investigator(s) 
leaving the site prior to study completion, an Investigator Financial Disclosure Form should be 
obtained at the end of his/her participation. 
15.8 
Investigator and Manufacturer Indemnity 
 
The investigator and the Sponsor will provide appropriate medical treatment and care in the event 
of a study related injury or illness. 
 
The sponsor has covered this study by means of insurance for the participant according to 
national requirements. The name and the address of the relevant insurance company, the 
certificate of insurance, the policy number, and the sum insured are provided in the Investigator’s 
File. 
 
 

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16. 
References 
 
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Murray CJ and Lopez AD. Alternative projections of mortality and disability by cause 1990-
2020: Global Burden of Disease Study. Lancet. 1997;349:1498-504. 
 
2. 
Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, Finkelstein 
EA, Hong Y, Johnston SC, Khera A, Lloyd-Jones DM, Nelson SA, Nichol G, Orenstein D, 
Wilson PW and Woo YJ. Forecasting the future of cardiovascular disease in the United 
States: a policy statement from the American Heart Association. Circulation. 2011;123:933-
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3. 
Kelly T, Yang W, Chen CS, Reynolds K and He J. Global burden of obesity in 2005 and 
projections to 2030. Int J Obes (Lond). 2008;32:1431-7. 
 
4. 
Ross R. Atherosclerosis is an inflammatory disease. Am Heart J. 1999;138:S419-20. 
 
5. 
Jonasson L, Holm J, Skalli O, Bondjers G and Hansson GK. Regional accumulations of T 
cells, macrophages, and smooth muscle cells in the human atherosclerotic plaque. 
Arteriosclerosis. 1986;6:131-8. 
 
6. 
Weber C and Noels H. Atherosclerosis: current pathogenesis and therapeutic options. Nat 
Med. 2011;17:1410-22. 
 
7. 
Falk E. Coronary thrombosis: pathogenesis and clinical manifestations. Am J Cardiol. 
1991;68:28B-35B. 
 
8. 
Finn AV, Nakano M, Narula J, Kolodgie FD and Virmani R. Concept of vulnerable/unstable 
plaque. Arterioscler Thromb Vasc Biol. 2010;30:1282-92. 
 
9. 
Naghavi M, Libby P, Falk E, Casscells SW, Litovsky S, Rumberger J, Badimon JJ, 
Stefanadis C, Moreno P, Pasterkamp G, Fayad Z, Stone PH, Waxman S, Raggi P, Madjid 
M, Zarrabi A, Burke A, Yuan C, Fitzgerald PJ, Siscovick DS, de Korte CL, Aikawa M, 
Airaksinen KE, Assmann G, Becker CR, Chesebro JH, Farb A, Galis ZS, Jackson C, Jang 
IK, Koenig W, Lodder RA, March K, Demirovic J, Navab M, Priori SG, Rekhter MD, Bahr R, 
Grundy SM, Mehran R, Colombo A, Boerwinkle E, Ballantyne C, Insull W, Jr., Schwartz RS, 
Vogel R, Serruys PW, Hansson GK, Faxon DP, Kaul S, Drexler H, Greenland P, Muller JE, 
Virmani R, Ridker PM, Zipes DP, Shah PK and Willerson JT. From vulnerable plaque to 
vulnerable patient: a call for new definitions and risk assessment strategies: Part II. 
Circulation. 2003;108:1772-8. 
 
10. Tawakol A, Migrino RQ, Bashian GG, Bedri S, Vermylen D, Cury RC, Yates D, LaMuraglia 
GM, Furie K, Houser S, Gewirtz H, Muller JE, Brady TJ and Fischman AJ. In vivo 18F-
fluorodeoxyglucose positron emission tomography imaging provides a noninvasive 
measure of carotid plaque inflammation in patients. J Am Coll Cardiol. 2006;48:1818-24. 
 
11. Virmani R, Kolodgie FD, Burke AP, Finn AV, Gold HK, Tulenko TN, Wrenn SP and Narula 
J. Atherosclerotic plaque progression and vulnerability to rupture: angiogenesis as a source 
of intraplaque hemorrhage. Arterioscler Thromb Vasc Biol. 2005;25:2054-61. 

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12. Joshi NV, Vesey AT, Williams MC, Shah AS, Calvert PA, Craighead FH, Yeoh SE, Wallace 
W, Salter D, Fletcher AM, van Beek EJ, Flapan AD, Uren NG, Behan MW, Cruden NL, Mills 
NL, Fox KA, Rudd JH, Dweck MR and Newby DE. 18F-fluoride positron emission 
tomography for identification of ruptured and high-risk coronary atherosclerotic plaques: a 
prospective clinical trial. Lancet. 2014;383:705-13. 
 
13. Kolodgie FD, Narula J, Burke AP, Haider N, Farb A, Hui-Liang Y, Smialek J and Virmani R. 
Localization of apoptotic macrophages at the site of plaque rupture in sudden coronary 
death. Am J Pathol. 2000;157:1259-68. 
 
14. Bjorkerud S and Bjorkerud B. Apoptosis is abundant in human atherosclerotic lesions, 
especially in inflammatory cells (macrophages and T cells), and may contribute to the 
accumulation of gruel and plaque instability. Am J Pathol. 1996;149:367-80. 
 
15. Tabas I. Macrophage death and defective inflammation resolution in atherosclerosis. Nat 
Rev Immunol. 2010;10:36-46. 
 
16. Clarke MC, Figg N, Maguire JJ, Davenport AP, Goddard M, Littlewood TD and Bennett MR. 
Apoptosis of vascular smooth muscle cells induces features of plaque vulnerability in 
atherosclerosis. Nat Med. 2006;12:1075-80. 
 
17. Bauriedel G, Hutter R, Welsch U, Bach R, Sievert H and Luderitz B. Role of smooth muscle 
cell death in advanced coronary primary lesions: implications for plaque instability. 
Cardiovasc Res. 1999;41:480-8. 
 
18. Kolodgie FD, Burke AP, Farb A, Gold HK, Yuan J, Narula J, Finn AV and Virmani R. The 
thin-cap fibroatheroma: a type of vulnerable plaque: the major precursor lesion to acute 
coronary syndromes. Curr Opin Cardiol. 2001;16:285-92. 
 
19. Virmani R, Burke AP, Kolodgie FD and Farb A. Vulnerable plaque: the pathology of 
unstable coronary lesions. J Interv Cardiol. 2002;15:439-46. 
 
20. Schwartzman RA and Cidlowski JA. Apoptosis: the biochemistry and molecular biology of 
programmed cell death. Endocr Rev. 1993;14:133-51. 
 
21. Koopman G, Reutelingsperger CP, Kuijten GA, Keehnen RM, Pals ST and van Oers MH. 
Annexin V for flow cytometric detection of phosphatidylserine expression on B cells 
undergoing apoptosis. Blood. 1994;84:1415-20. 
 
22. Hofstra L, Liem IH, Dumont EA, Boersma HH, van Heerde WL, Doevendans PA, De Muinck 
E, Wellens HJ, Kemerink GJ, Reutelingsperger CP and Heidendal GA. Visualisation of cell 
death in vivo in patients with acute myocardial infarction. Lancet. 2000;356:209-12. 
 
23. Kietselaer BL, Reutelingsperger CP, Heidendal GA, Daemen MJ, Mess WH, Hofstra L and 
Narula J. Noninvasive detection of plaque instability with use of radiolabeled annexin A5 in 
patients with carotid-artery atherosclerosis. N Engl J Med. 2004;350:1472-3. 
 
24. Kolodgie FD, Petrov A, Virmani R, Narula N, Verjans JW, Weber DK, Hartung D, Steinmetz 
N, Vanderheyden JL, Vannan MA, Gold HK, Reutelingsperger CP, Hofstra L and Narula J. 

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Targeting of apoptotic macrophages and experimental atheroma with radiolabeled annexin 
V: a technique with potential for noninvasive imaging of vulnerable plaque. Circulation. 
2003;108:3134-9. 
 
25. Ishino S, Kuge Y, Takai N, Tamaki N, Strauss HW, Blankenberg FG, Shiomi M and Saji H. 
99mTc-Annexin A5 for noninvasive characterization of atherosclerotic lesions: imaging and 
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rabbits. Eur J Nucl Med Mol Imaging. 2007;34:889-99. 
 
26. Lahorte CM, Vanderheyden JL, Steinmetz N, Van de Wiele C, Dierckx RA and Slegers G. 
Apoptosis-detecting radioligands: current state of the art and future perspectives. Eur J 
Nucl Med Mol Imaging. 2004;31:887-919. 
 
27. Tait JF, Smith C and Blankenberg FG. Structural requirements for in vivo detection of cell 
death with 99mTc-annexin V. J Nucl Med. 2005;46:807-15. 
 
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Vanderheyden JL, Green AM and Verbeke K. Safety, biodistribution, and dosimetry of 
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31. Mathiesen EB, Bonaa KH and Joakimsen O. Echolucent plaques are associated with high 
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A. Increased uptake of the apoptosis-imaging agent (99m)Tc recombinant human Annexin 
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Appendix I – Radiolabeling procedure of rh-Annexin V-128 and quality controls 
 
Radiolabeling procedure 
The technetium solution to be used for the labeling of rh-Annexin V-128 kit is the solution which 
can be obtained from commercially available Tc generators compliant with the Ph.Eur. 
Monograph “Sodium Pertechnetate (99mTc) Injection (Fission)” and Tc 99m Injection USP. 
During the product development, the following procedures and conditions have been tested and 
confirmed as adequate: 
a. Radioactive concentration of the pertechnetate solution added for labelling should be 370 
MBq/mL (the reconstitution volume is 2 mL ± 0.2 mL). 
b. Labelling at room temperature under slight rotation by introducing the vial in a shielded 
roller for 90 min: shorter incubation times may result in inadequate labelling. 
c. Stability of the radiolabelled compound: up to 6hours at room temperature (RCP  90 %). 
d. Suitability of the Radio TLC method to determine the radiochemical yield and purity by 
using three different eluents: acetone 100% (99mTcO4-, Rf=1.0); anticoagulant citrate 
dextrose solution (ACD) (99mTc-rhAnnexin V-128, Rf=0.0); PBS (99mTc-Glucoheptonate, 
Rf=1.0 and 99mTcO2,Rf=0.0). 
The labelling takes place through an exchange reaction with 99m-Technetium-Glucoheptonate. 
 
 
Scheme of the exchange reaction between 99mTc-Glucoheptonate (99mTc-GH) and rhAnnexin V-
128. 
 
The instructions for the preparation of the 99mTc-rhAnnexin V-128 are in accordance with the 
following aseptic procedure: 
1) Remove one rhAnnexin V128 Kit reaction vial from refrigerated storage and allow it to 
reach room temperature (from 5 to 10 minutes). 
2) Waterproof gloves should be worn during the preparation procedure. Flip off cap from 
the rhAnnexin V-128 Kit vial and swab the top of the vial closure with an appropriate 
antiseptic to disinfect the surface, and then allow the stopper to dry. 
3) Place the vial in a suitable radiation shield appropriately labelled with date, time of 
preparation, volume and activity. 
4) Aseptically add 2 mL ± 0.2 mL of sodium pertechnetate Tc-99m solution containing 740 
MBq ± 74 MBq (20 mCi ± 2 mCi) to the vial in the lead shield (Do not shake). 

A A A- A n n e xi n- 0 4 
 
P a g e 3 5 of 4 5 
St u d y Pr ot o c ol  
 
C o nfi d e nti al 
V e rsi o n 5 .0 , 2 F e br u ar y 2 0 1 8 
5) 
R e m o v e t h e vi al fr o m t h e l e a d s hi el d a n d pl a c e it i n a n a p pr o pri at el y s hi el d e d r oll er. 
L e a v e t h e vi al u n d er sl o w r ot ati o n f or 9 0 mi n.   
6) 
R e m o v e t h e vi al fr o m t h e s hi el d e d r oll er, i n s p e ct vi s u all y f or t h e a b s e n c e of p arti c ul at e 
m att er a n d di s c ol or ati o n a n d pl a c e it a g ai n i n a l e a d s hi el d. 
7) 
A s e pti c all y wit h dr a w m at eri al u si n g a st eril e s hi el d e d s yri n g e. T h e s o- o bt ai n e d s ol uti o n i s 
st a bl e f or 6 h o ur s aft er c o m pl eti o n of r a di ol a b elli n g r e a cti o n. F or t h e p ur p o s e of t hi s 
st u d y, it i s r e c o m m e n d e d t o u s e it wit hi n 4 h o ur s aft er pr e p ar ati o n. 
8) 
R a di o c h e mi c al p urit y s h o ul d b e c h e c k e d pri or t o p ati e nt a d mi ni str ati o n a c c or di n g t o t h e 
R a di o T L C M et h o d. 
 
C a uti o n ar y N ot e s: 
•  
T c- 9 9 m p ert e c h n et at e el u at e s h o ul d b e o bt ai n e d fr o m a g e n er at or w hi c h h a s b e e n 
el ut e d wit hi n t h e l a st 2 4 h o ur s. 
•  
T c- 9 9 m p ert e c h n et at e el u at e w hi c h i s m or e t h a n 6- h o ur ol d fr o m t h e ti m e of 
el uti o n s h o ul d N O T b e u s e d . 
 
 

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Stability and Shelf Life of the Kit for radiopharmaceutical preparation of 99mTc-rhAnnexin 
V-128 
 
Stability evaluation was performed so far on the lab-scale, engineering and first GMP batches. 
Stability data indicate that the product is stable up to 12 months both at 5°C ± 3°C (long term 
condition) and up to 9 months at 25°C ± 2°C/60% RH ± 5% RH (accelerated conditions), with 
high radiochemical purity (RCP, well above 90%) and good biological activity (Biopotency, 
higher than 90%). Since the Drug Product confirmed to be stable after 12 months of storage at 
the accelerated temperature conditions (25°C ± 2°C/60% RH ± 5% RH), the current applied 
shelf-life is 12 months at 5°C ± 3°C. 
 
The stability evaluation will be performed on future GMP batches in order to obtain complete 
stability data on at least three GMP batches of the Drug Product up to 12 months at the 
intended long term storage temperature (5°C ± 3°C).  As mentioned above, the stability 
assessment is being also performed at the accelerated temperature condition (25°C ± 2°C/60% 
RH ± 5% RH), up to 9 months. 
 
  
 
Stability of the Finished Product (99mTc-rhAnnexin V-128 radiolabelled Imaging Agent) 
 
The stability of the Finished Product is 6 h after labeling at room temperature. At this time the 
radiochemical purity is still  90%. For the purpose of this study it is recommended to inject the 
product within 4 hours after completion of the radiolabelling reaction. 
 
 

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Serious Adverse Event (SAE) Reporting Form 
 
 
ALL REPORTS MUST BE SIGNED AND DATED BY THE INVESTIGATOR. 
 
Please fax or send by e-mail the form to AAA Global Pharmacovigilance within 24 hours from 
awareness of event. 
 
E-mail: 
 
 
Fax N°: 
 
 
 
Study Name 
EudraCT N° 
Center N° 
Investigator N° 
Country 
 
 
 
 
 
 
 
TYPE OF REPORT 
 
 
 Initial 
 
 
 Completion of data 
 
 
 Follow-up 
 
 
1. PATIENT DATA - DO NOT SEND PATIENT IDENTIFIABLE DATA 
Patient Initials 
(first letter of First 
Name and first letter 
of Last Name): 
Last name    
First name    
Patient N°:
Sex:
 
Year of Birth
(yyyy): 
 
Age at onset of 
event: 
 
 
Weight (kg):
 
Height (cm): 
 
 
2. EVENT DETAILS
Date of onset 
(dd/mm/yyyy): 
 
Diagnosis: 
 
 
Description of SAE (please state date of first use): 
 
 
 
 
 
 
 
Seriousness Criteria (check all that are relevant to the event): 
 Participant died                          
 Hospitalisation or prolongation of existing hospitalisation 

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 Life-threatening                          
 Persistent or significant disability or incapacity 
 
 Congenital anomaly/                  
 Other significant medical events 
            birth defect 
 
 
Severity of event:                        
 
Mild                            
 Moderate                               
 
Severe 



3. STUDY TREATMENT
Drug 
Schedule 
Route of 
administration 
Start date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Causally Related to Drug? 
Tick either unrelated or 
possibly related
Expected 
(Y/N) 
Unrelated 
Possibly 
Related
1. 
 
 
 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
 
 
4. 
 
 
 
 
 
 
 
 

4. NIMPs (Non-investigational medicinal products)
Are there any additional medications used as part of the protocol?  Such medications are referred to 
as NIMPs 
Yes 
  
 
 
 
 
 
No 
 
If yes, please complete the table below 
NIMP(s) 
Dose/schedule 
Route of 
administration 
Start date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Causally Related to 
NIMP?  
Tick either unrelated or 
possibly related
Expected 
(Y/N/NA) 
Unrelated 
Possibly 
Related
1. 
 
 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
 
 
 

5. CONCOMITANT DRUGS RELEVANT TO THE SAE (do not include therapy used to treat 
the SAE) 
Tick box if no relevant concomitant medication
Drug name 
Dose/schedule 
Route of 
administration
Reason 
for use
Start date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Continued? 
(Y/N) 
1. 
 
 
 
 
 
 
 
 
2. 
 
 
 
 
 
 

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Version 5.0, 2 February 2018 
 
3. 
 
 
 
 
 
 
 
 
4. 
 
 
 
 
 
 
 
 
5. 
 
 
 
 
 
 
 
 
6. 
 
 
 
 
 
 
 


6. MEDICAL HISTORY (list relevant medical history): 
Tick box if no relevant medical history
Condition 
Start Date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Ongoing 
(Y/N) 
Medication required 
Y/N
1. 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
4. 
 
 
 
 
 

7. RELEVANT TEST/LABORATORY FINDINGS (include only the results relevant to the SAE 
diagnosis or course of SAE)  
Test/lab 
finding 
Unit  
Date 
(dd/mm/yyyy) 
Value 
Reference range 
1. 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
4. 
 
 
 
 
 
 
Comment on test/laboratory findings (if none, mark as NA) 
 
 
 
 
 
 

8. ACTION TAKEN (check all that are relevant to the SAE) 
 No action taken  
 
 Drug permanently 
discontinued due to this 
 Concomitant medication 
taken  

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SAE  
 
 
 Drug schedule 
adjusted/temporarily 
interrupted  
 
If multiple drugs used, please 
record which drug(s) have 
been adjusted/interrupted: 
 Non-drug therapy given 
 Hospitalisation/prolonged 
hospitalisation  

9. OUTCOME OF SAE
 Completely recovered 
Date of recovery 
(dd/mm/yyyy) 
 
 Condition still present and 
unchanged 
 Recovered with sequelae 
Date (dd/mm/yyyy) 
Describe sequale: 
 
 Condition deteriorated 
 
 
 
 Condition improving 
 Death  
Date of death (dd/mm/yyyy) 
 
 
Autopsy:  
Yes 
     No 
     N/A 
 
If Yes, include relevant information: 
 

10. ADDITIONAL INFORMATION 
 
 
 
 
 

11. INFORMATION SOURCE
Name, address and 
telephone number of PI 
 
 
 
 
 
Date of report (dd/mm/yyyy)
 
PI signature 
 
 
 
 
 
 
 
 
 
 
 

AAA-Annexin-04 
 
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Version 5.0, 2 February 2018 
 
 
 
 
 
TO BE COMPLETED BY AAA GLOBAL PV (INTERNAL USE ONLY) 
 
DATE OF RECEIPT: 
(dd/mm/yyyy)
AAA CASE TRACKING NUMBER: 


INFORMATION COMPLETE: 
 Yes  
 No  
 
 
Name and signature: 
 
 
FOLLOW-UP REQUESTED:  
 YES 
 
 NO  
Details: 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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PREGNANCY REPORTING FORM  
ALL REPORTS MUST BE SIGNED AND DATED BY THE INVESTIGATOR. 
Please fax or send by e-mail the form to AAA Global Pharmacovigilance within 24 hours from 
awareness of event. 
E-mail: 
 
Fax N° : 
 
 
N.B : Fill the applicable fields and refer to Completion Guide of Pregnancy Reporting Form. 
TYPE OF REPORT:      Initial       Completion of data         Follow-up n° ………………       
                                                                       
Study Name
EudraCT N°
Center N°
Investigator N°
Country
 
 
 
 
 
 
 

2. PREGNANT WOMAN’S GENERAL MEDICAL HISTORY / BACKGROUND 
BACKGROUND  
PRIOR IMMUNIZATIONS 
Rhesus: 
Smoking: 
Alcohol:  
Drug abuse(s): 
  Unknown    Rh -    Rh + 
  Unknown    No      Yes ….…….……………. (pack-years) 
  Unknown    No      Yes ....….…….…..……. (glasses/day) 
  Unknown    No      Yes ....……….…..…………... (detail) 
Rubella: 
Toxoplasma: 
  Unknown   No    Yes   
  Unknown   No    Yes   
MEDICAL HISTORY 
VIRAL SEROLOGY  
Hypertension: 
Diabetes mellitus: 
Epilepsy:  
Psychiatric diseases: 
  Unknown    No      Yes   
  Unknown    No      Yes   
  Unknown    No      Yes   
  Unknown    No      Yes   
HIV: 
Hepatitis: 
  Unknown   No    Yes   
  Unknown   No    Yes   

3. PREGNANT WOMAN’S GYNECOLOGICAL & OBSTETRICAL HISTORY 
GYNECOLOGICAL HISTORY 
1. PATIENT INFORMATION 
Patient initials (first letter of Last Name and first 
letter of First Name)
                       Last name    
               First name  
Patient N°: 
Birthdate (YYYY): 
        
   Age: ……………… 
Weight (kg): 
  
Height (cm):  

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Used contraception: 
Regular menses: 
Infertility treatment: 
  None     Oral    Local    Intra-uterine device    Other   …………………………..…………………………. (detail) 
  No        Yes    
  No        Yes   …………………………..……………………………………………………………………….……… (detail) 
OBSTETRICAL HISTORY 
Gravidity: 
Parity: 
  No    Yes ………………………….. (detail)  
  No    Yes ………………………….. (detail) 
Abortions:  
 
 
 
 
 
  No    Yes 
If yes, please precise: 
  Spontaneous ……………….…………… (detail) 
  Elective …………………….…………….. (detail) 
  Therapeutic ……………….…..…………. (detail) 
In utero demise: 
  No    Yes ………………………….. (detail) 
Number of healthy live offspring:   
Number of death offspring:   
Number of malformated live offspring:  
…………………………   
…………………………   
…………………………   

4. MATERNAL & PATERNAL FAMILY HISTORY 
Malformations: 
Prematurely died children: 
Psychomotor retardation: 
Consanguinity: 
Hereditary disease: 
Other: 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
……………………………………………………………………..….………………………………………...… (detail) 


5. CURRENT PREGNANCY STATUS AT TIME OF DETECTION 
Last menstrual period:
    /     /         
 
Gestational age: ……………………. 
Ultrasound-estimated gestational age: …………………… 
 
Polyzygotic pregnancy:  
Ectopic pregnancy :  
 
  No     Yes 
  No     Yes 
Estimated date of delivery: 
    /     /         

6. COURSE OF CURRENT PREGNANCY 
DELETERIOUS EXPOSURES DURING PREGNANCY 
PATHOLOGY (IES) DURING PREGNANCY 
Smoker: 
Alcohol:  
Drug abuse(s) : 
Other : 
  No     Yes ……...……………………………..  (pack-years) 
  No     Yes ……………………………………….  (glasses/day) 
  No     Yes ……………………………………….........  (detail) 
…………………………………………………………………………. 
Hypertension : 
Diabetes: 
Infection :  
Other : 
  No     Yes  
  No     Yes  
  No     Yes  
……………………………. 
MEDICATION RECEIVED AFTER PREGNANCY DETECTION 
Name 
 
Posology 
(with units) 
Administration 
route 
Indication(s)  
Administration dates (start/end)  
1.  
 
 
 
 
2.  
 
 
 
 
3.  
 
 
 
 

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4.  
 
 
 
 
5.  
 
 
 
 
MEDICAL FOLLOW-UP 
Hospitalization during pregnancy:  
Intrauterine growth retardation: 
Prenatal diagnosis:  
  No     Yes    ………………………………………...………………………………………...... (reason) 
  No     Yes    ………………………………………...………………………………………........ (detail) 
  No     Yes     
Ultrasound: 
  No     Yes  
If yes, please precise: 
 
 
Date:     /     /         
Date:     /     /         
Date:     /     /         
Results: ………………………………………... 
Results: ………………………………………... 
Results: ………………………………………... 
Invasive method:  
  No     Yes 
If yes, please precise: ………………………………………... (method) 
 
Date:     /     /         
Results: ………………………………………... 
Toxicology screen:  
  No     Yes 
If yes, please precise: ………………………………………... (drug / body fluid) 
 
Date:     /     /         
Results: ………………………………………... (level) 

7. OUTCOME OF CURRENT PREGNANCY 
Live newborn:
  No     Yes 
If NO, please precise: 
 
  Spontaneous abortion 
  Elective abortion 
  Therapeutic abortion 
  In utero demise 
Date:     /     /          
Date:     /     /         
Date:     /     /         
 
Term: ……………………… (week) 
Term: ……………………… (week) 
Term: ……………………… (week) 
Term: ……………………… (week) 
Malformations: 
Histopathology:
  No     Yes  
  No     Yes 
……………………………………………………………...  (detail) 
……………………………………………………………...  (detail) 

8. DELIVERY 
Delivery date:
    /     /         
  Normal delivery 
  Induced delivery   
  Caesarean section 
Fetal distress:  
Normal placenta: 
Amniotic fluid:  
  No     Yes    (If yes)   Chronic    Acute 
  No     Yes    Unknown 
  Clear     Turbid 
Gestational age: 
…………………………. (weeks) 
Postpartum maternal condition: 
Intrapartum medication:
  Normal         Abnormal     
  Unknown     No     Yes    
…………………………………………………..…….  (detail) 
…………………………………………………..…….  (if yes, detail) 

9. NEWBORN 
Sex :     F     M   
Weight: ………………………..... (unit) 
Preterm:         No     Yes  
Dysmature:    No     Yes   
Intensive care:    
  No     Yes    Unknown 
  No     Yes ………………………...  (detail) 

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Length: …………………….….... (unit) 
Cranial perimeter: ………......... (unit) 
APGAR score: ……..…. (1 min)    
                          ……..…. (5 min) 
Malformation :  
Neonatal pathology:  
Breastfeeding: 
  No     Yes ………………………...  (detail) 
  No     Yes   
Transfer to NICU / pediatrics:  
Immediate outcome: 
  No    Yes  ….……..  (duration) 
………………………...................... 
Department address:  
Child’s follow-up performed by: 
………………………...………………… 
………………………...………………… 

10. INITIAL REPORTER
 
Occupation:  
 
Full name:  
 
Organization/Adress:  
 
Telephone:  
Fax:  
Email:  
 
Date & signature  ______________________________________   
 
If the reporter is a patient or not a Healthcare Professional: 
Has the patient given the authorization to AAA to follow up the pregnancy 
with its treating Doctor?    Yes     No   
Date & signature  __________________________________ 
 
Details of the treating Doctor (if different from the reporter): 
Occupation:  
Full name:  
Organization/Address:  
Telephone/Fax:  
Email:  


ADMINISTRATIVE INFORMATION (for internal use only) 
AAA Case #: ……………………………………………. 
TYPE DE RAPPORT:      Initial     Follow up n°: ……………… 
Initial reception by: 
NAME:  
OCCUPATION:  
LOCAL AFFILIATE/COUNTRY:  
DATE:       /     /         
 
 SIGNATURE   _________________________________________ 
Reception date by AAA PV department 
    /     /         
Reception date by a partner 
    /     /         

Data collected during a Pharmacovigilance investigation may be stored in a database according to Regulation (UE) no 520/2012, Regulation (CE) no 
726/2004 and directive 2001/83/CE.