Reduced thrombogenicity of nitinol stents--in vitro evaluation of different surface modifications and coatings

Impact of heart valve decellularization on 3-D ultrastructure, immunogenicity and thrombogenicity

Decellularized xenogeneic tissue represents an interesting material for heart valve tissue engineering. The prospect objective is removal of all viable cells while preserving extracellular matrix (ECM) integrity. The major concerns of all decellularization protocols remain ECM disruption, immunogenicity and thrombogenicity. Accordingly the aim of this study was visualization of ultrastructural ECM disruption and human immune response and thrombogenicity using different decellularization protocols of porcine heart valves. Porcine pulmonary leaflets were decellularized with four different protocols: sodium deoxycholate, sodium dedecylsulfate, trypsin/EDTA, and trypsin-detergent-nuclease. Then the tissues were processed for histology and two-photon laser scanning microscopy (LSM). For thrombogenicity and immunogenicity testing tissues were incubated with human blood. The histological examination revealed no remaining cells and no significant differences in the ECM histoarchitecture in any group. LSM detected significant ECM alterations in all groups except sodium deoxycholate group with an almost completely preserved ECM. There was no increased immunogenicity between fresh and decellularized tissue. Compared to GA-fixed tissue however significantly increased immune responses and thrombogenicity was observed in all protocols. From our experiment, sodium deoxycholate enables cell removal with almost complete preservation of ECM structures. And all of these four decellularization protocols affected human immunological response and increased thrombogenicity.

Shape memory alloys: metallurgy, biocompatibility, and biomechanics for neurosurgical applications

SHAPE MEMORY ALLOYS possess distinct dynamic properties with particular applications in neurosurgery. Because of their unique physical characteristics, these materials are finding increasing application where resiliency, conformation, and actuation are needed. Nitinol, the most frequently manufactured shape memory alloy, responds to thermal and mechanical stimuli with remarkable mechanical properties such as shape memory effect, super-elasticity, and high damping capacity. Nitinol has found particular use in the biomedical community because of its excellent fatigue resistance and biocompatibility, with special interest in neurosurgical applications. The properties of nitinol and its diffusionless phase transformations contribute to these unique mechanical capabilities. The features of nitinol, particularly its shape memory effect, super-elasticity, damping capacity, as well as its biocompatibility and biomechanics are discussed herein. Current and future applications of nitinol and other shape memory alloys in endovascular, spinal, and minimally invasive neurosurgery are introduced. An understanding of the metallurgic properties of nitinol provides a foundation for further exploration of its use in neurosurgical implant design.

Thin film nitinol microstent for aneurysm occlusion

Thin film nitinol produced by sputter deposition was used in the design of microstents intended to treat small vessel aneurysms. Thin film microstents were fabricated by "hot-target" dc sputter deposition. Both stress-strain curves and differential scanning calorimetry curves were generated for the film used to fabricate stents. The films used for stents had an A(f) temperature of approximately 36 degrees C allowing for body activated response from a microcatheter. The 10 microm film was only slightly radio-opaque; thus, a Td marker was attached to the stents to guide fluoroscopic delivery. Thin film microstents were tested in a flow loop with and without nitinol support skeletons to give additional radial support. Stents could be compressed into and easily delivered with <3 Fr catheters. Theoretical frictional and wall drag forces on a thin film nitinol small vessel vascular stent were calculated, and the radial force exerted by thin film stents was evaluated theoretically and experimentally. In vivo studies in swine confirmed that thin film nitinol microstents could be deployed accurately and consistently in the swine cranial vasculature.

The electrochemical characteristics of native Nitinol surfaces

The present study explored the avenues for the improvement of native Nitinol surfaces for implantation obtained using traditional procedures such as mechanical polishing, chemical etching, electropolishing and heat treatments for a better understanding of their electrochemical behavior and associated surface stability, conductivity, reactivity and biological responses. The corrosion resistance (cyclic potential polarization, open circuit potential and polarization resistance) of Nitinol disc and wire samples were evaluated for various surface states in strain-free and strained wire conditions. The surface response to tension strain was studied in situ. Surface chemistry and structure were explored using XPS and Auger spectroscopy and photoelectrochemical methods, respectively. It was found that the polarization resistance of the Nitinol surfaces varied in a range from 100 kOmega to 10 MOmega cm(2) and the open circuit potentials from -440 mV to -55 mV. The surfaces prepared in chemical solutions showed consistent corrosion resistance in strain-free and strained states, but mechanically polished and heat treated samples were prone to pitting. Nitinol surface oxides are semiconductors with the band gaps of either 3.0 eV (rutile) or 3.4 eV (amorphous). The conductivity of semiconducting Nitinol surfaces relevant to their biological performances is discussed in terms of oxide stoichiometry and variable Ni content. Such biological characteristics of Nitinol surfaces as Ni release, fibrinogen adsorption and platelets behavior are re-examined based on the analysis of the results of the present study.

Silicon carbide coating of nitinol stents to increase antithrombogenic properties and reduce nickel release

BACKGROUND

The use of stents in the superficial femoral artery is still limited by the number of restenoses. Influencing factors include thrombus formation and smooth muscle cell proliferation as well as motion stress. A reduction of thrombogenicity can be achieved by passive coating with silicon carbide, which induces less thrombus formation due to its semiconducting properties.

METHODS AND MATERIALS

Self-expanding peripheral stents with and without silicon carbide coating were examined in a chandler loop model. Assessed parameters included thrombocyte count, beta-thromboglobulin (TG), thrombin-antithrombin (TAT) III complex, and polymorphonuclear elastase. Nickel release was quantified at Days 1, 3, and 223 using graphite furnace atomic absorption spectrometry. To visualize thrombus formation on the surface, scanning electron microscopy was conducted.

RESULTS

The tests showed a superiority of the coated stents regarding beta-TG (484.0+/-180.2 IU/l vs 2189.1+/-898.9 IU/l) as well as formation of TAT III complex (16.0+/-19.1 microg/l vs 458.3+/-761.0 microg/l). Scanning electron microscopy revealed a nearly absent thrombus formation on the coating. Nickel release was reduced by more than 90% at all time points.

CONCLUSIONS

In the provided in vitro setting, silicon carbide coating applied to self-expanding peripheral stents showed an advantage regarding thrombogenicity. The passive barrier resulted in a limited release of nickel from the alloy itself. These features seem promising for the use in the peripheral vasculature.

The role of stents in the treatment of congenital heart disease: Current status and future perspectives

Intravascular or intracardiac stenoses occur in many forms of congenital heart disease (CHD). Therefore, the implantation of stents has become an accepted interventional procedure for stenotic lesions in pediatric cardiology. Furthermore, stents are know to be used to exclude vessel aneurysm or to ensure patency of existing or newly created intracardiac communications. With the further refinement of the first generation of devices, a variety of "modern" stents with different design characteristics have evolved. Despite the tremendous technical improvement over the last 20 years, the "ideal stent" has not yet been developed. Therefore, the pediatric interventionalist has to decide which stent is suitable for each lesion. On this basis, currently available stents are discussed in regard to their advantages and disadvantages for common application in CHD. New concepts and designs developed to overcome some of the existing problems, like the failure of adaptation to somatic growth, are presented. Thus, in the future, biodegradable or growth stents might replace the currently used generation of stents. This might truly lead to widening indications for the use of stents in the treatment of CHD.

Electrohydrodynamic Jetting Behaviour of Polyhedral Oligomeric Silsesquioxane Nanocomposite

In this paper, we investigate in detail the electrohydrodynamic spraying of a nonbiodegradable nanocomposite polyhedral oligomeric silsesquioxane polymer developed in our laboratories and currently being explored for coating metallic stent materials. Different concentrations of the polymer have been dissolved to prepare, characterise, and electrohydrodynamically deposit the polymer on stainless steel. From the experiments, the solution containing 15 wt% polymer was selected for further investigation. The variation of film/ coating thickness as a function of spraying time was studied and the structural features of the film were assessed using microscopy. Films were also tensile tested. This study has identified a process and conditions which can be used in our stent coating research.

Critical overview of Nitinol surfaces and their modifications for medical applications

Nitinol, a group of nearly equiatomic shape memory and superelastic NiTi alloys, is being extensively explored for medical applications. Release of Ni in the human body, a potential problem with Nitinol implant devices, has stimulated a great deal of research on its surface modifications and coatings. In order to use any of the developed surfaces in implant designs, it is important to understand whether they really have advantages over bare Nitinol. This paper overviews the current situation, discusses the advantages and disadvantages of new surfaces as well as the limitations of the studies performed. It presents a comprehensive analysis of surface topography, chemistry, corrosion behavior, nickel release and biological responses to Nitinol surfaces modified mechanically or using such methods as etching in acids and alkaline solutions, electropolishing, heat and ion beam treatments, boiling in water and autoclaving, conventional and ion plasma implantations, laser melting and bioactive coating deposition. The analysis demonstrates that the presently developed surfaces vary in thickness from a few nanometers to micrometers, and that they can effectively prevent Ni release if the surface integrity is maintained under strain and if no Ni-enriched sub-layers are present. Whether it is appropriate to use various low temperature pre-treatment protocols (< or = 160 degrees C) developed originally for pure titanium for Nitinol surface modifications and coatings is also discussed. The importance of selection of original Nitinol surfaces with regard to the performance of coatings and comparative performance of controls in the studies is emphasized. Considering the obvious advantages of bare Nitinol surfaces for superelastic implants, details of their preparation are also outlined.

Biostability and biological performance of a PDMS-based polyurethane for controlled drug release

Polymers have been used to deliver therapeutic agents in a range of medical devices with drug eluting stents being the most widespread current application. Although polymers enable controlled release of a therapeutic agent, the polymeric surface has been reported to provide suboptimal biocompatibility and haemocompatibility and it has been suggested that currently used polymers may be at least partly responsible for the late adverse events observed in intravascular stent systems. In this study, the biostability and biological performance of a siloxane-based polyurethane elastomer (E2A) demonstrating excellent long-term biostability in the unloaded state was investigated following incorporation of a therapeutic agent. After implantation in an ovine model for 6 months, samples were assessed using SEM and ATR-FTIR to determine changes in the surface chemical structure and morphology of the materials and tensile testing was used to examine changes in bulk characteristics. Biological response was assessed using in vitro cytotoxicity testing and histological analysis. Results indicated that incorporation of 25mg/g dexamethasone acetate (DexA) into the siloxane-based polyurethane resulted in no significant difference in the biostability and biocompatibility of the material. Some level of cytotoxic potential was exhibited which was believed to result from residual DexA leaching from samples during the extraction process. These findings suggest that E2A is a potential candidate for a delivery vehicle of therapeutic agents in implantable drug delivery applications.

Synthesis and Modifications of Polyurethanes for Biomedical Purposes

Polyurethanes are known as a class of polymers with very high ‘hemocompatible‘ properties. In this study polyurethanes were prepared in various compositions and in medical purity without using any solvent, catalyst or additives. For the synthesis of polyurethanes, toluene diisocynate, diphenylmethane diisocynate or hexamethylene diisocynate were used as diisocyanate compounds and polypropylene-ethylene glycol or polypropylene glycol were used as polyol compounds. The surfaces were modified with plasma glow-discharge by using various gas atmospheres and by applying different powers. Some samples were also modified by heparin immobilization to increase the blood compatibility. Chemical structure, mechanical strength, thermal behavior, oxygen permeability, water contact angle values, as well as protein and cell attachment capabilities of the prepared and modified polyurethanes were examined as possible candidates for biomedical applications. Plasma altered the chemistry of the surface, increased hydrophilic character, and caused a decrease in protein adsorption as the applied power was increased. On the other hand, an optimum power value which caused maximum attachment for Vero cells was observed. In-vitro experiments carried out with blood cells, plasma modification caused an increase on cell adhesion while further heparin immobilization resulted with a significant decrease.

Application of a New Suture Material Called the U-Clip for Composite and Sequential Grafting with Off-Pump Coronary Bypass Surgery

BACKGROUND

The U-Clip was found to facilitate the interrupted anastomosis of coronary artery bypass grafts (CABG). This device may be beneficial especially in multivessel off-pump CABG (OPCAB) using composite grafts or sequential anastomosis. The aim of this study was to evaluate our early clinical experience using the U-Clip in OPCAB cases.

METHODS

This retrospective study included 118 patients who underwent off-pump CABG between 2001 and 2004. The mean age of the 91 men and 27 women was 69.5 +/- 8.0 years (range, 47-85). The U-Clip was adopted for sewing 73 proximal ends of the free graft to the side or end of the inflow conduit to prepare the composite graft. The U-Clip was also applied to 112 distal anastomoses, especially to the side-to-side anastomosis of the sequential graft.

RESULTS

Hospital mortality rate was 0.8% (1/118). The early patency rate of distal anastomoses using the U-Clip was 95% (96/101). The early patency rate of proximal anastomoses using the U-Clip was 98.4% (62/63). Interim angiography was performed in 12 patients (range, 3.8-42 months; average, 16 months). In these 12 patients, a total of 8 proximal anastomoses of conduits using the U-Clip were all patent without stenosis. The patency rate of a total of 10 distal anastomoses in the 12 patients using the U-Clip was 100%.

CONCLUSIONS

The U-Clip-interrupted anastomosis enables a safe, definite, and rapid end-to-end or end-to-side connection of arterial grafts. We therefore consider the U-Clip to be a useful suture material especially for multivessel OPCAB using multiple arterial grafts.

Shape Memory Alloys for Biomedical Applications

NiTi shape memory alloy (SMA) products appeared to the medical markets in 1980’s, their global market being more than US$ 130 billion in 2002. In most medical applications material must be biocompatible. NiTi offers the bodytemperature activated shape memory effect (SME), superelasticity (SE) and the damping capacity, which all can be applied in medical use. The dental arch wires and stents are benefiting from SE. The NiTi vena cava filters obtain their umbrella shaped mesh when SMEactivated. Generally the NiTi tubes and guidewires are applied in the minimally invasive medical procedures and in the interventional radiology. There are numerous steerable, hingeless, kink resistant, highly flexible clinical instruments that may provide constant force. NiTi is used for the dental implants and the attachments of the partial dentures and for the orthopaedics. In the latter one the main applications are the clamps for connecting bone fractures or parts for e.g. the spinal bentcalibration bar. Miniaturization has enabled small SMAactuators that are applicable in active endoscopes with allround bending and in actuators for kidney or heart pumps. The main risks using NiTi are the insecure fatigue life and possible cytotoxicity.

Chronic performance of polyurethane catheters covalently coated with ATH complex: A rabbit jugular vein model

Covalent complexes of antithrombin (AT) and heparin (ATH) have superb anticoagulant activity towards thrombin and factor Xa. Stability of polyurethane central venous catheters covalently modified with radiolabeled ATH was studied using a roller pump with saline or protease P-5147. Saline wash removed loosely bound ATH molecules to decrease graft density from 26 to 12 pmol/cm2. However, only slightly more ATH was removed by strong protease (from 12 to 7 pmol/cm2). To evaluate ATH-coated, heparin-coated, and uncoated catheters, a chronic rabbit jugular vein model was developed with catheters maintained for up to 30-106 days. Lumen occlusion was tested by drawing blood twice daily. Although unmodified or heparin-coated catheters occluded within 5-7 days after insertion, all ATH catheters remained patent throughout the experiment. Scanning electron microscopy (SEM) analysis of heparin and uncoated catheters revealed extensive thrombosis (lumen+mural) while ATH catheters were unaffected. Visual observation showed significant deposition of protein and cells on control and heparin-modified catheters and, to a lesser degree, on ATH-coated surfaces. SEM showed no fibrin inside or outside of ATH catheters, which remained patent in extended studies out to 106 days. Although atomic force microscopy showed ATH coatings to be rough, 6-fold higher anti-factor Xa activity likely contributed to increased patency. Our data confirm that ATH-modified catheters are stable and have superior potency compared to heparin or control catheters.

Controlled delivery of antisense oligodeoxynucleotide from cationically modified phosphorylcholine polymer films

Antisense strategy is a promising approach for the prevention of in-stent restenosis if therapeutic agents such as antisense oligodeoxynucleotides (AS-ODNs) can be successfully delivered to the implant site. Optimizing the routes and conditions for controlled loading and release of therapeutic agents from a biocompatible polymer coating is still required. In this study, phosphorylcholine (PC) polymer films bearing different cationic charge densities were deposited onto smooth silicon substrates. The thickness of these films was determined by spectroscopic ellipsometry (SE). Human c-myc AS-ODNs were incorporated into the PC polymer films by immersion in concentrated AS-ODN solution and eluted into PBS under physiological conditions. The elution profile was monitored by UV spectrometry and gel electrophoresis. Cellular uptake of the eluted AS-ODN into vascular smooth muscle cells (VSMCs) was evaluated by fluorescence microscopy. The results showed that ODN loading capacities increased with film thickness and were also strongly dependent on the cationic charge density. AS-ODN release was characterized by a slight initial burst in the first half hour followed by a period of sustained release up to 8 days. Gel electrophoresis demonstrated DNA integrity, and different transfection efficiencies were observed when the eluted ODNs were transfected into VSMCs. These results demonstrated that cationically modified PC polymers are capable of delivery of antisense ODNs in a controlled manner and that they are well suited for specific biomedical devices such as DNA-eluting stents.

Stent-Protected Carotid Angioplasty Using a Membrane Stent: A Comparative Cadaver Study

PURPOSE

To evaluate the performance of a prototype membrane stent, MembraX, in the prevention of acute and late embolization and to quantify particle embolization during carotid stent placement in human carotid explants in a proof of concept study.

METHODS

Thirty human carotid cadaveric explants (mild stenoses 0-29%, n = 23; moderate stenoses 30-69%, n = 3; severe stenoses 70-99%, n = 2) that included the common, internal and external carotid arteries were integrated into a pulsatile-flow model. Three groups were formed according to the age of the donors (mean 58.8 years; sample SD 15.99 years) and randomized to three test groups: (I) MembraX, n = 9; (II) Xpert bare stent, n = 10; (III) Xpert bare stent with Emboshield protection device, n = 9. Emboli liberated during stent deployment (step A), post-dilatation (step B), and late embolization (step C) were measured in 100 microm effluent filters. When the Emboshield was used, embolus penetration was measured during placement (step D) and retrieval (step E). Late embolization was simulated by compressing the area of the stented vessel five times.

RESULTS

Absolute numbers of particles (median; >100 microm) caught in the effluent filter were: (I) MembraX: A = 7, B = 9, C = 3; (II) bare stent: A = 6.5, B = 6, C = 4.5; (III) bare stent and Emboshield: A = 7, B = 7, C.=.5, D = 8, E = 10. The data showed no statistical differences according to whether embolic load was analyzed by weight or mean particle size. When summing all procedural steps, the Emboshield caused the greatest load by weight (p = 0.011) and the largest number (p = 0.054) of particles.

CONCLUSIONS

On the basis of these limited data neither a membrane stent nor a protection device showed significant advantages during ex vivo carotid angioplasty. However, the membrane stent seems to have the potential for reducing the emboli responsible for supposed late embolization, whereas more emboli were observed when using a protection device. Further studies are necessary and warranted.