A blood vessel model constructed from collagen and cultured vascular cells

3D bioprinting of vascular conduits for pediatric congenital heart repairs

In children with congenital heart defects, surgical correction often involves the use of valves, patches or vascular conduits to establish anatomic continuity. Due to the differences between the pediatric and adult populations, tissue reconstruction in pediatric patients requires a substantially different approach from those in adults. Cardiovascular anatomy of children with congenital heart defect vary, which requires tailored surgical operations for each patient. Since grafts used in these palliative surgeries are sensitive to the local hemodynamic environments, their geometries need to be precisely designed to ensure long-term performance. Tissue engineered vascular grafts (TEVGs) have made tremendous progress over the past decade, but it remains difficult to fabricate patient- and operation-specific vascular grafts. This review summarizes historical milestones of TEVG development for repairing pediatric congenital defects and current clinical outcomes. We also highlight ongoing works on 3D bioprinting of TEVGs with complex geometries and address the current limitations of each technique. Although 3D bioprinted vascular grafts with appropriate functions are yet to be developed, some of the current researches are promising to create better patient specific tissue engineered vascular grafts in the future.

In Silico Tissue Engineering: A Coupled Agent-Based Finite Element Approach

Over the past two decades, the increase in prevalence of cardiovascular diseases and the limited availability of autologous blood vessels and saphenous vein grafts have motivated the development of tissue-engineered vascular grafts (TEVGs). However, compliance mismatch and poor mechanical properties of the TEVGs remain as two major issues that need to be addressed. Researchers have investigated the role of various culture conditions and mechanical conditioning in deposition and orientation of collagen fibers, which are the key structural components in the vascular wall; however, the intrinsic complexity of mechanobiological interactions demands implementing new engineering approaches that allow researchers to investigate various scenarios more efficiently. In this study, we utilized a coupled agent-based finite element analysis (AB-FEA) modeling approach to study the effect of various loading modes (uniaxial, biaxial, and equibiaxial), boundary conditions, stretch magnitudes, and growth factor concentrations on growth and remodeling of smooth muscle cell-populated TEVGs, with specific focus on collagen deposition and orientation. Our simulations (12 weeks of culture) showed that biaxial cyclic loading (and not uniaxial or equibiaxial) leads to alignment of collagen fibers in the physiological directions. Moreover, axial boundary conditions of the TEVG act as determinants of fiber orientations. Decreasing the serum concentration, from 10% to 5% or 1%, significantly decreased the growth and remodeling speed, but only affected the fiber orientation in the 1% serum case. In conclusion, in silico tissue engineering has the potential to evolve the future of tissue engineering, as it will allow researchers to conceptualize various interactions and investigate numerous scenarios with great speed. In this study, we were able to predict the orientation of collagen fibers in TEVGs using a coupled AB-FEA model in less than 8 h. Impact Statement Tissue-engineered vascular grafts (TEVGs) hold potential to replace the current gold standard of vascular grafting, saphenous vein grafts. However, developing TEVGs that mimic the mechanical performance of the native tissue remains a challenging task. We developed a computational model of the grafts' remodeling processes and studied the effects of various loading mechanisms and culture conditions on collagen fiber orientation, which is a key factor in mechanical performance of the grafts. We were able to predict the fiber orientations accurately and show that biaxial loading and axial boundary conditions are important factors in collagen fiber organization.

3D printed coaxial nozzles for the extrusion of hydrogel tubes toward modeling vascular endothelium

Engineered tubular constructs made from soft biomaterials are employed in a myriad of applications in biomedical science. Potential uses of these constructs range from vascular grafts to conduits for enabling perfusion of engineered tissues and organs. The fabrication of standalone tubes or complex perfusable constructs from biofunctional materials, including hydrogels, via rapid and readily accessible routes is desirable. Here we report a methodology in which customized coaxial nozzles are 3D printed using commercially available stereolithography (SLA) 3D printers. These nozzles can be used for the fabrication of hydrogel tubes via coextrusion of two shear-thinning hydrogels: an unmodified Pluronic® F-127 (F127) hydrogel and an F127-bisurethane methacrylate (F127-BUM) hydrogel. We demonstrate that different nozzle geometries can be modeled via computer-aided design and 3D printed in order to generate tubes or coaxial filaments with different cross-sectional geometries. We were able to fabricate tubes with luminal diameters or wall thicknesses as small as ∼150 μm. Finally, we show that these tubes can be functionalized with collagen I to enable cell adhesion, and human umbilical vein endothelial cells can be cultured on the luminal surfaces of these tubes to yield tubular endothelial monolayers. Our approach could enable the rapid fabrication of biofunctional hydrogel conduits which can ultimately be utilized for engineering in vitro models of tubular biological structures.

Collagen-Based Tissue Engineering Strategies for Vascular Medicine

Cardiovascular diseases (CVDs) account for the 31% of total death per year, making them the first cause of death in the world. Atherosclerosis is at the root of the most life-threatening CVDs. Vascular bypass/replacement surgery is the primary therapy for patients with atherosclerosis. The use of polymeric grafts for this application is still burdened by high-rate failure, mostly caused by thrombosis and neointima hyperplasia at the implantation site. As a solution for these problems, the fast re-establishment of a functional endothelial cell (EC) layer has been proposed, representing a strategy of crucial importance to reduce these adverse outcomes. Implant modifications using molecules and growth factors with the aim of speeding up the re-endothelialization process has been proposed over the last years. Collagen, by virtue of several favorable properties, has been widely studied for its application in vascular graft enrichment, mainly as a coating for vascular graft luminal surface and as a drug delivery system for the release of pro-endothelialization factors. Collagen coatings provide receptor-ligand binding sites for ECs on the graft surface and, at the same time, act as biological sealants, effectively reducing graft porosity. The development of collagen-based drug delivery systems, in which small-molecule and protein-based drugs are immobilized within a collagen scaffold in order to control their release for biomedical applications, has been widely explored. These systems help in protecting the biological activity of the loaded molecules while slowing their diffusion from collagen scaffolds, providing optimal effects on the targeted vascular cells. Moreover, collagen-based vascular tissue engineering substitutes, despite not showing yet optimal mechanical properties for their use in the therapy, have shown a high potential as physiologically relevant models for the study of cardiovascular therapeutic drugs and diseases. In this review, the current state of the art about the use of collagen-based strategies, mainly as a coating material for the functionalization of vascular graft luminal surface, as a drug delivery system for the release of pro-endothelialization factors, and as physiologically relevant in vitro vascular models, and the future trend in this field of research will be presented and discussed.

Rapid and efficient in vivo angiogenesis directed by electro-assisted bioprinting of alginate/collagen microspheres with human umbilical vein endothelial cell coating layer

Rapid reconstruction of functional microvasculature is the urgent challenge of regenerative medicine and ischemia therapy development. The purpose of this study was to provide an alternative solution for obtaining functional blood vessel networks in vivo, through assessing whether hydrogel-based microspheres coated by human umbilical vein endothelial cells (HUVECs) can direct rapid and efficient in vivo angiogenesis without the addition of exogenous growth factors or other supporting cells. Uniform alginate microspheres with adjustable diameter were biofabricated by electro-assisted bioprinting technology. Collagen fibrils were evenly coated on the surface of alginate microspheres through simple self-assembly procedure, and collagen concentration is optimized to achieve the highest HUVECs adhesion and proliferation. Immunofluorescence staining and gene analysis confirmed the formation of the prevascularized tubular structure and significantly enhanced endothelial gene expression. HUVECs-coated hydrogel microspheres with different diameters were subcutaneously injected in immune-deficient mice, which demonstrated rapid blood vessel regeneration and functional anastomosis with host blood vessels within 1 week. Besides, microsphere diameter demonstrated influence on blood vessel density with statistical differences but showed no obvious influence on the area occupied by blood vessels. This study provided a powerful tool for rapid and minimal-invasion angiogenesis of bioprinting constructs and a potential method for vascularized tissue regeneration and ischemia treatment with clinically relevant dimensions.

A model of guided cell self-organization for rapid and spontaneous formation of functional vessels

Most achievements to engineer blood vessels are based on multiple-step manipulations such as manual sheet rolling or sequential cell seeding followed by scaffold degradation. Here, we propose a one-step strategy using a microfluidic coextrusion device to produce mature functional blood vessels. A hollow alginate hydrogel tube is internally coated with extracellular matrix to direct the self-assembly of a mixture of endothelial cells (ECs) and smooth muscle cells (SMCs). The resulting vascular structure has the correct configuration of lumen, an inner lining of ECs, and outer sheath of SMCs. These "vesseloids" reach homeostasis within a day and exhibit the following properties expected for functional vessels (i) quiescence, (ii) perfusability, and (iii) contractility in response to vasoconstrictor agents. Together, these findings provide an original and simple strategy to generate functional artificial vessels and pave the way for further developments in vascular graft and tissue engineering and for deciphering the angiogenesis process.

Development of In Vitro Bioengineered Vascular Grafts for Microsurgery and Vascular Surgery Applications

Introduction

The use of vascular grafts is continuing to rise due to the increasing prevalence of coronary artery bypass grafting and microvascular flap-based tissue reconstructions. The current options of using native vessels (saphenous vein) or the synthetic grafts (Dacron) have been unable to manage current needs. In this study, we employed an original tissue engineering approach to develop a multi-layered vascular graft that has the potential to address some of the limitations of the existing grafts.

Materials and Methods

Biomaterials, gelatin and fibrin, were used to develop a two-layered vascular graft. The graft was seeded with endothelial cells and imaged using confocal microscopy. The graft's architecture and its mechanical properties were also characterized using histology, Scanning Electron Microscopy and rheological studies.

Results

Our methodology resulted in the development of a vascular graft with precise spatial localization of the two layers. The endothelial cells fully covered the lumen of the developed vascular graft, thus providing a non-thrombogenic surface. The elastic modulus of the biomaterials employed in this graft was found to be 5.186 KPa, paralleling that of internal mammary artery. The burst pressure of this graft was also measured and was found close to that of the saphenous vein (~2000 mm Hg).

Conclusions

We were successfully able to employ a unique method to synthesize a multi-layered vascularized graft having adequate biological and mechanical properties. Studies are ongoing involving implantation of this developed vascular graft in the rat femoral artery and characterization of parameters such as vascular remodeling and patency.

Engineering blood vessels and vascularized tissues: technology trends and potential clinical applications

Vascular tissue engineering has the potential to make a significant impact on the treatment of a wide variety of medical conditions, including providing in vitro generated vascularized tissue and organ constructs for transplantation. Since the first report on the construction of a biological blood vessel, significant research and technological advances have led to the generation of clinically relevant large and small diameter tissue engineered vascular grafts (TEVGs). However, developing a biocompatible blood-contacting surface is still a major challenge. Researchers are using biomimicry to generate functional vascular grafts and vascular networks. A multi-disciplinary approach is being used that includes biomaterials, cells, pro-angiogenic factors and microfabrication technologies. Techniques to achieve spatiotemporal control of vascularization include use of topographical engineering and controlled-release of growth/pro-angiogenic factors. Use of decellularized natural scaffolds has gained popularity for engineering complex vascularized organs for potential clinical use. Pre-vascularization of constructs prior to implantation has also been shown to enhance its anastomosis after implantation. Host-implant anastomosis is a phenomenon that is still not fully understood. However, it will be a critical factor in determining the in vivo success of a TEVGs or bioengineered organ. Many clinical studies have been conducted using TEVGs, but vascularized tissue/organ constructs are still in the research & development stage. In addition to technical challenges, there are commercialization and regulatory challenges that need to be addressed. In this review we examine recent advances in the field of vascular tissue engineering, with a focus on technology trends, challenges and potential clinical applications.

Autologous endothelialized vein allografts in coronary artery bypass surgery - Long term results

BACKGROUND

Lack of autologous graft material restricts the ability to treat patients requiring coronary artery bypass surgery (CABG). An off the shelf tissue engineered small diameter vascular graft is the holy grail of cardiovascular surgery.

METHODS

Allograft saphenous veins were harvested from organ donors, cryopreserved, deendothelialized and then seeded with autologous endothelial cells prior to implantation during coronary artery bypass surgery. All patients treated were followed-up until death and angiographic results were collected. Grafts were explanted during autopsy and immunohistochemistry was performed.

RESULTS

Twelve patients received 15 engineered grafts. Mean patient survival was 9.1 ± 1.8 years. Six month graft patency was 80 (95% CI: 59-100) and 9 month graft patency was 50 (95% CI: 27-93) - graft patency detected up to 32 months after surgery. Immunohistochemistry in grafts explanted showed a presence of CD31 and CD68 positive cells in the luminal region of the vessel walls and layers of Collagen Type I in the abluminal vessel walls.

CONCLUSIONS

Our small diameter tissue engineered vascular graft shows openness up to 32 months after implantation. Immunohistochemistry suggests that monocyte activation may lead to vessel remodeling with thickening of the vessel wall. Research should concentrate on a manipulation of remodeling processes.

Mechanical properties of l-lysine based segmented polyurethane vascular grafts and their shape memory potential

Segmented polyurethanes based on polycaprolactone, 4,4 (metylene-bis-cyclohexyl) isocyanate, and l-lysine were synthesized, manufactured as small vascular grafts and characterized according to ISO 7198 standard for cardiovascular implants-tubular vascular prosthesis. In terms of mechanical properties, the newly synthesized polyurethane films exhibited lower secant modulus than Tecoflex™ SG 80A, a well-known medical grade polyurethane. Similarly, when tested as grafts, the l-lysine-based polyurethane exhibited lower longitudinal failure load (11.5 N vs. 116 N), lower circumferential failure load per unit length (5.67 N/mm vs. 14.0 N/mm) and lower suture forces for both nylon (13.3 N vs. 24.0 N) and silk (14.0 N vs. 19.3 N) when compared to Tecoflex™ SG 80A grafts. l-Lysine-based graft exhibited a burst strength of 3620 mmHg (482.6 kPa) and a compliance of 0.16%/mmHg. The cell adhesion was demonstrated with NIH/3T3 fibroblasts where cell adhesion was observed on both films and grafts, while cell alignment was observed only on the grafts. The mechanical properties of this polyurethane and the possibility of strain-induced PCL crystals as the switching phase for shape memory materials, allowed a strain recovery ratio and a strain fixity ratio with values higher than 95% and 90%, respectively, with a repeatability of the shape-memory properties up to 4 thermo-mechanical cycles. Overall, the properties of lysine-based polyurethanes are suitable for large diameter vascular grafts where cell alignment can be controlled by their shape memory potential.

The Evolution of Tissue Engineered Vascular Graft Technologies: From Preclinical Trials to Advancing Patient Care

Currently available synthetic grafts have contributed to improved outcomes in cardiovascular surgery. However, the implementation of these graft materials at small diameters have demonstrated poor patency, inhibiting their use for coronary artery bypass surgery in adults. Additionally, when applied to a pediatric patient population, they are handicapped by their lack of growth ability. Tissue engineered alternatives could possibly address these limitations by producing biocompatible implants with the ability to repair, remodel, grow, and regenerate. A tissue engineered vascular graft (TEVG) generally consists of a scaffold, seeded cells, and the appropriate environmental cues (i.e., growth factors, physical stimulation) to induce tissue formation. This review critically appraises current state-of-the-art techniques for vascular graft production. We additionally examine current graft shortcomings and future prospects, as they relate to cardiovascular surgery, from two major clinical trials.

Concise Review: Patency of Small-Diameter Tissue-Engineered Vascular Grafts: A Meta-Analysis of Preclinical Trials

Several patient groups undergoing small‐diameter (<6 mm) vessel bypass surgery have limited autologous vessels for use as grafts. Tissue‐engineered vascular grafts (TEVG) have been suggested as an alternative, but the ideal TEVG remains to be generated, and a systematic overview and meta‐analysis of clinically relevant studies is lacking. We systematically searched PubMed and Embase databases for (pre)clinical trials and identified three clinical and 68 preclinical trials ([>rabbit]; 873 TEVGs) meeting the inclusion criteria. Preclinical trials represented low to medium risk of bias, and binary logistic regression revealed that patency was significantly affected by recellularization, TEVG length, TEVG diameter, surface modification, and preconditioning. In contrast, scaffold types were less important. The patency was 63.5%, 89%, and 100% for TEVGs with a median diameter of 3 mm, 4 mm, and 5 mm, respectively. In the group of recellularized TEVGs, patency was not improved by using smooth muscle cells in addition to endothelial cells nor affected by the endothelial origin, but seems to benefit from a long‐term (46–240 hours) recellularization time. Finally, data showed that median TEVG length (5 cm) and median follow‐up (56 days) used in preclinical settings are relatively inadequate for direct clinical translation. In conclusion, our data imply that future studies should consider a TEVG design that at least includes endothelial recellularization and bioreactor preconditioning, and we suggest that more standard guidelines for testing and reporting TEVGs in large animals should be considered to enable interstudy comparisons and favor a robust and reproducible outcome as well as clinical translation.

Regeneration of a neoartery through a completely autologous acellular conduit in a minipig model: a pilot study

Background

Vascular grafts are widely used as a treatment in coronary artery bypass surgery, hemodialysis, peripheral arterial bypass and congenital heart disease. Various types of synthetic and natural materials were experimented to produce tissue engineering vascular grafts. In this study, we investigated in vivo tissue engineering technology in miniature pigs to prepare decellularized autologous extracellular matrix-based grafts that could be used as vascular grafts for small-diameter vascular bypass surgery.

Methods

Autologous tissue conduits (3.9 mm in diameter) were fabricated by embedding Teflon tubings in the subcutaneous pocket of female miniature pigs (n = 8, body weight 25–30 kg) for 4 weeks. They were then decellularized by CHAPS decellularization solution. Heparin was covalently-linked to decellularized tissue conduits by Sulfo-NHS/EDC. We implanted these decellularized, completely autologous extracellular matrix-based grafts into the carotid arteries of miniature pigs, then sacrificed the pigs at 1 or 2 months after implantation and evaluated the patency rate and explants histologically.

Results

After 1 month, the patency rate was 100% (5/5) while the inner diameter of the grafts was 3.43 ± 0.05 mm (n = 5). After 2 months, the patency rate was 67% (2/3) while the inner diameter of the grafts was 2.32 ± 0.14 mm (n = 3). Histological staining confirmed successful cell infiltration, and collagen and elastin deposition in 2-month samples. A monolayer of endothelial cells was observed along the inner lumen while smooth muscle cells were dominant in the graft wall.

Conclusion

A completely autologous acellular conduit with excellent performance in mechanical properties can be remodeled into a neoartery in a minipig model. This proof-of-concept study in the large animal model is very encouraging and indicates that this is a highly feasible idea worthy of further study in non-human primates before clinical translation.

Recellularization potential of small diameter vascular grafts derived from human umbilical artery

BACKGROUND

The primary therapeutic strategy in cardiovascular disease is the coronary artery bypass surgery, which in- volves the use of small diameter vascular grafts (<6 mm). Human umbilical arteries could be used as a source for the development of these grafts.

OBJECTIVE

The aim of this study was the decellularization of human umbilical arteries and the evaluation of their re- cellularization potential.

METHODS

Decellularization of human umbilical arteries was performed with a detergent based protocol. Histological analysis was performed in order to determine the effect of decellularization. Then, recellularization was performed by using two different approaches. The first approach was the dynamic seeding of human umbilical arteries with Mesenchymal Stromal Cells and the second approach involved the recellularization by using a bioreactor system.

RESULTS

Histological analysis showed the successful removal of cellular and nuclear materials from the umbilical arteries. In addition, successful recellularization of the vessels was observed with both approaches.

CONCLUSION

The results of this study indicated that human umbilical arteries could serve as an alternative material for the proper development of small diameter vascular grafts.

Polymerization induced phase separation as a generalized methodology for multi-layered hydrogel tubes

Herein, we report a conceptually chemical strategy to facilitate the fabrication of layered hydrogel tubes based on the polymerization-induced phase separation mechanism.

Chitosan/hyaluronic acid multilayer films are biocompatible substrate for Wharton's jelly derived stem cells

Background

Discovery of mesenchymal stem cells (MSCs) in various adult human tissues opened the way to new therapeutic strategies involving tissue engineering from these cells. More recently, vascular substitutes have opened the era of vascular engineering by making replacement vessels from purely biological material. The objective of our study was to create a vascular substitute from MSCs using a multilayer polyelectrolyte film based on natural polymers (Chitosan and Hyaluronic Acid).

Methods

Biocompatibility and cellular behavior were evaluated in this study using MSCs from the Wharton's jelly (WJ) of human umbilical cords. WJ-MSCs adherence was assessed and cells morphology was investigated by Scanning Electron Microscopy (SEM) and actin visualization (Phalloidin).

Results

The number of WJ-MSCs seeded on the (CHI/HA)₁₀ films was greater than the number of cells seeded on the collagen, as the spectrophotometric measurement showed a large cell proliferation on (CHI/HA)₁₀ in comparison with collagen. After adhesion, WJ-MSCs showed a fibroblastic morphology on CHI/HA as for control (collagen I). These results were confirmed by cytoskeleton staining.

Conclusions

The biocompatibility of WJ-MSCs and (CHI/HA)₁₀ showed the possibility to combine the use of WJ-MSCs and (CHI/HA)₁₀ films in vascular tissue engineering.

Systematic in vitro comparison of decellularization protocols for blood vessels

Decellularization of native blood vessels is a promising technology to generate 3D biological scaffolds for vascular grafting. Blood vessel decellularization has been performed in previous studies under various experimental conditions, that complicates comparison and optimization of suitable protocols. The goal of this work was to systematically compare the decellularization and recellularization efficacy of 5 different protocols utilizing the detergents sodium dodecyl sulfate (SDS), sodium deoxycholate (SDC), CHAPS and TritonX-100 together with DNA-removing enzymes on porcine vena cava in a perfusion bioreactor setup. Additionally, we tested the effect of DNase on the extracellular matrix (ECM) properties. We found that all protocols could efficiently decellularize blood vessels. Mechanical strength, collagen preservation and ECM integrity were similar among all tested detergents, yet TritonX protocols required long-term DNase application for complete decellularization. However, TritonX-based protocols showed the greatest recellularization efficacy with HUVECs in vitro. Furthermore, we developed a novel protocol for TritonX which improved recellularization and reduced total process time and ECM stiffness compared to previous protocols. SDS, SDC and CHAPS based protocols had a lower recellularization potential. In conclusion, decellularization of blood vessels can be achieved with all tested reagents, but TritonX treated ECM can be most efficiently recellularized with endothelial cells.

Functionalized core/shell nanofibers for the differentiation of mesenchymal stem cells for vascular tissue engineering

AIM

Atherosclerosis is a common cardiovascular disease causing medical problems globally leading to coronary artery bypass surgery. The present study is to fabricate core/shell nanofibers to encapsulate VEGF for the differentiation of mesenchymal stem cells (MSCs) into smooth muscle cells to develop vascular grafts.

MATERIALS & METHODS

The fabricated core/shell nanofibers contained polycaprolactone/gelatin as the shell, and silk fibroin/VEGF as the core materials.

RESULTS

The results observed that the core/shell nanofibers interact to differentiate MSCs into smooth muscle cells by the expression of vascular smooth muscle cell (VSMC) contractile proteins α-actinin, myosin and F-actin.

CONCLUSION

The functionalized polycaprolactone/gelatin/silk fibroin/VEGF (250 ng) core/shell nanofibers were fabricated for the controlled release of VEGF in a persistent manner for the differentiation of MSCs into smooth muscle cells for vascular tissue engineering.

Cardiac Stem Cell Patch Integrated with Microengineered Blood Vessels Promotes Cardiomyocyte Proliferation and Neovascularization after Acute Myocardial Infarction

Cardiac stem cell (CSC) therapy has shown preclinical and clinical evidence for ischemic heart repair but is limited by low cellular engraftment and survival after transplantation. Previous versions of the cardiac patch strategy improve stem cell engraftment and encourage repair of cardiac tissue. However, cardiac patches that can enhance cardiomyogenesis and angiogenesis at the injured site remain elusive. Therapies that target cardiomyocyte proliferation and new blood vessel formation hold great potential for the protection against acute myocardial infarction (MI). Here, we report a new strategy for creating a vascularized cardiac patch in a facile and modular fashion by leveraging microfluidic hydrodynamic focusing to construct the biomimetic microvessels (BMVs) that include human umbilical vein endothelial cells (HUVECs) lining the luminal surface and then encapsulating the BMVs in a fibrin gel spiked with human CSCs. We show that the endothelialized BMVs mimicked the natural architecture and function of capillaries and that the resultant vascularized cardiac patch (BMV-CSC patch) exhibited equivalent release of paracrine factors compared to those of coculture of genuine human CSCs and HUVECs after 7 days of in vitro culture. In a rat model of acute MI, the BMV-CSC patch therapy induced profound mitotic activities of cardiomyocytes in the peri-infarct region 4 weeks post-treatment. A significant increase in myocardial capillary density was noted in the infarcted hearts that received BMV-CSC patch treatment compared to the infarcted hearts treated with conventional CSC patches. The striking therapeutic benefits and the fast and facile fabrication of the BMV-CSC patch make it promising for practical applications. Our findings suggest that the BMV-CSC patch strategy may open up new possibilities for the treatment of ischemic heart injury.

Quickening: Translational design of resorbable synthetic vascular grafts

Traditional tissue-engineered vascular grafts have yet to gain wide clinical use. The difficulty of scaling production of these cell- or biologic-based products has hindered commercialization. In situ tissue engineering bypasses such logistical challenges by using acellular resorbable scaffolds. Upon implant, the scaffolds become remodeled by host cells. This review describes the scientific and translational advantages of acellular, synthetic vascular grafts. It surveys in vivo results obtained with acellular synthetics over their fifty years of technological development. Finally, it discusses emerging principles, highlights strategic considerations for designers, and identifies questions needing additional research.

Tissue Engineering at the Blood-Contacting Surface: A Review of Challenges and Strategies in Vascular Graft Development

Tissue engineered vascular grafts (TEVGs) are beginning to achieve clinical success and hold promise as a source of grafting material when donor grafts are unsuitable or unavailable. Significant technological advances have generated small-diameter TEVGs that are mechanically stable and promote functional remodeling by regenerating host cells. However, developing a biocompatible blood-contacting surface remains a major challenge. The TEVG luminal surface must avoid negative inflammatory responses and thrombogenesis immediately upon implantation and promote endothelialization. The surface has therefore become a primary focus for research and development efforts. The current state of TEVGs is herein reviewed with an emphasis on the blood-contacting surface. General vascular physiology and developmental challenges and strategies are briefly described, followed by an overview of the materials currently employed in TEVGs. The use of biodegradable materials and stem cells requires careful control of graft composition, degradation behavior, and cell recruitment ability to ensure that a physiologically relevant vessel structure is ultimately achieved. The establishment of a stable monolayer of endothelial cells and the quiescence of smooth muscle cells are critical to the maintenance of patency. Several strategies to modify blood-contacting surfaces to resist thrombosis and control cellular recruitment are reviewed, including coatings of biomimetic peptides and heparin.

A completely biological "off-the-shelf" arteriovenous graft that recellularizes in baboons

Prosthetic arteriovenous grafts (AVGs) conventionally used for hemodialysis are associated with inferior primary patency rates and increased risk of infection compared with autogenous vein grafts. We tissue-engineered an AVG grown from neonatal human dermal fibroblasts entrapped in bovine fibrin gel that is then decellularized. This graft is both "off-the-shelf" (nonliving) and completely biological. Grafts that are 6 mm in diameter and about 15 cm in length were evaluated in a baboon model of hemodialysis access in an axillary-cephalic or axillary-brachial upper arm AVG construction procedure. Daily antiplatelet therapy was given. Grafts underwent both ultrasound assessment and cannulation at 1, 2, 3, and 6 months and were then explanted for analysis. Excluding grafts with cephalic vein outflow that rapidly clotted during development of the model, 3- and 6-month primary patency rates were 83% (5 of 6) and 60% (3 of 5), respectively. At explant, patent grafts were found to be extensively recellularized (including smoothelin-positive smooth muscle cells with a developing endothelium on the luminal surface). We observed no calcifications, loss of burst strength, or outflow stenosis, which are common failure modes of other graft materials. There was no overt immune response. We thus demonstrate the efficacy of an off-the-shelf AVG that is both acellular and completely biological.

Fibronectin promotes elastin deposition, elasticity and mechanical strength in cellularised collagen-based scaffolds

One of the tightest bottlenecks in vascular tissue engineering (vTE) is the lack of strength and elasticity of engineered vascular wall models caused by limited elastic fiber deposition. In this study, flat and tubular collagen gel-based scaffolds were cellularised with vascular smooth muscle cells (SMCs) and supplemented with human plasma fibronectin (FN), a known master organizer of several extracellular matrix (ECM) fiber systems. The consequences of FN on construct maturation was investigated in terms of geometrical contraction, viscoelastic mechanical properties and deposition of core elastic fiber proteins. FN was retained in the constructs and promoted deposition of elastin by SMCs as well as of several proteins required for elastogenesis such as fibrillin-1, lysyl oxidase, fibulin-4 and latent TGF-β binding protein-4. Notably, gel contraction, tensile equilibrium elastic modulus and elasticity were strongly improved in tubular engineered tissues, approaching the behaviour of native arteries. In conclusion, this study demonstrates that FN exerts pivotal roles in directing SMC-mediated remodeling of scaffolds toward the production of a physiological-like, elastin-containing ECM with excellent mechanical properties. The developed FN-supplemented systems are promising for tissue engineering applications where the generation of mature elastic tissue is desired and represent valuable advanced in vitro models to investigate elastogenesis.

Animal models of cardiovascular disease as test beds of bioengineered vascular grafts

The last two decades have seen many advances in regenerative medicine, including the development of tissue engineered vessels (TEVs) for replacement of damaged or diseased arteries or veins. Biomaterials from natural sources as well as synthetic polymeric materials have been employed in engineering vascular grafts. Recently, cell-free grafts have become available opening new possibilities for the next generation, off-the-shelf products. These TEVs are first tested in small or large animal models, which are usually young and healthy. However, the majority of patients in need of vascular grafts are elderly and suffer from comorbidities that may complicate their response to the implants. Therefore, it is important to evaluate TEVs in animal models of vascular disease in order to increase their predictive value and learn how the disease microenvironment may affect the patency and remodeling of vascular grafts. Small animals with various disease phenotypes are readily available due to the availability of transgenic or gene knockout technologies and can be used to address mechanistic questions related to vascular grafting. On the other hand, large animal models with similar anatomy, hematology and thrombotic responses to humans have been utilized in a preclinical setting. We propose that large animal models with certain pathologies or age range may provide more clinically relevant platforms for testing TEVs and facilitate the clinical translation of tissue engineering technologies by increasing the likelihood of success in clinical trials.

Increasing Cell Seeding Density Improves Elastin Expression and Mechanical Properties in Collagen Gel-Based Scaffolds Cellularized with Smooth Muscle Cells

Vascular tissue engineering combines cells with scaffold materials in vitro aiming the development of physiologically relevant vascular models. For natural scaffolds such as collagen gels, where cells can be mixed with the material solution before gelation, cell seeding density is a key parameter that can affect extracellular matrix deposition and remodeling. Nonetheless, this parameter is often overlooked and densities sensitively lower than those of native tissues, are usually employed. Herein, the effect of seeding density on the maturation of tubular collagen gel-based scaffolds cellularized with smooth muscle cells is investigated. The compaction, the expression, and deposition of key vascular proteins and the resulting mechanical properties of the constructs are evaluated up to 1 week of maturation. Results show that increasing cell seeding density accelerates cell-mediated gel compaction, enhances elastin expression (more than sevenfold increase at the highest density, Day 7) and finally improves the overall mechanical properties of constructs. Of note, the tensile equilibrium elastic modulus, evaluated by stress-relaxation tests, reach values comparable to native arteries for the highest cell density, after a 7-day maturation. Altogether, these results show that higher cell seeding densities promote the rapid maturation of collagen gel-based vascular constructs toward structural and mechanical properties better mimicking native arteries.

A Microfluidic System for the Investigation of Tumor Cell Extravasation

Metastatic dissemination of cancer cells is a very complex process. It includes the intravasation of cells into the metastatic pathways, their passive distribution within the blood or lymph flow, and their extravasation into the surrounding tissue. Crucial steps during extravasation are the adhesion of the tumor cells to the endothelium and their transendothelial migration. However, the molecular mechanisms that are underlying this process are still not fully understood. Novel three dimensional (3D) models for research on the metastatic cascade include the use of microfluidic devices. Different from two dimensional (2D) models, these devices take cell⁻cell, structural, and mechanical interactions into account. Here we introduce a new microfluidic device in order to study tumor extravasation. The device consists of three different parts, containing two microfluidic channels and a porous membrane sandwiched in between them. A smaller channel together with the membrane represents the vessel equivalent and is seeded separately with primary endothelial cells (EC) that are isolated from the lung artery. The second channel acts as reservoir to collect the migrated tumor cells. In contrast to many other systems, this device does not need an additional coating to allow EC growth, as the primary EC that is used produces their own basement membrane. VE-Cadherin, an endothelial adherence junction protein, was expressed in regular localization, which indicates a tight barrier function and cell⁻cell connections of the endothelium. The EC in the device showed in vivo-like behavior under flow conditions. The GFP-transfected tumor cells that were introduced were of epithelial or mesenchymal origin and could be observed by live cell imaging, which indicates tightly adherent tumor cells to the endothelial lining under different flow conditions. These results suggest that the new device can be used for research on molecular requirements, conditions, and mechanism of extravasation and its inhibition.

3D biofabrication for tubular tissue engineering

The therapeutic replacement of diseased tubular tissue is hindered by the availability and suitability of current donor, autologous and synthetically derived protheses. Artificially created, tissue engineered, constructs have the potential to alleviate these concerns with reduced autoimmune response, high anatomical accuracy, long-term patency and growth potential. The advent of 3D bioprinting technology has further supplemented the technological toolbox, opening up new biofabrication research opportunities and expanding the therapeutic potential of the field. In this review, we highlight the challenges facing those seeking to create artificial tubular tissue with its associated complex macro- and microscopic architecture. Current biofabrication approaches, including 3D printing techniques, are reviewed and future directions suggested.

Design, characterization and in vivo performance of synthetic 2 mm-diameter vessel grafts made of PVA-gelatin blends

Since the development of the first vascular grafts, fabrication of vessel replacements with diameters smaller than 6 mm remains a challenge. The present work aimed to develop PVA (poly (vinyl alcohol))-gelatin hybrids as tubes suitable for replacement of very small vessels and to evaluate their performance using a rat abdominal aorta interposition model. PVA-gelatin hybrid tubes with internal and external diameters of 1.4 mm and 1.8 mm, respectively, composed of 4 different gelatin ratios were prepared using a one-step strategy with both chemical and physical crosslinking. By 3D Time of Flight MRI, Doppler-Ultrasound, Computed Tomography angiography and histology, we demonstrated good patency rates with the 1% gelatin composition until the end of the study at 3 months (50% compared to 0% of PVA control grafts). A reduction of the patency rate during the time of implantation suggested some loss of properties of the hybrid material in vivo, further confirmed by mechanical evaluation until one year. In particular, stiffening and reduction of compliance of the PVA-gelatin grafts was demonstrated, which might explain the observed long-term changes in patency rate. These encouraging results confirm the potential of PVA-gelatin hybrids as ready-to-use vascular grafts for very small vessel replacement.

Current Strategies for the Manufacture of Small Size Tissue Engineering Vascular Grafts

Occlusive arterial disease, including coronary heart disease (CHD) and peripheral arterial disease (PAD), is the main cause of death, with an annual mortality incidence predicted to rise to 23.3 million worldwide by 2030. Current revascularization techniques consist of angioplasty, placement of a stent, or surgical bypass grafting. Autologous vessels, such as the saphenous vein and internal thoracic artery, represent the gold standard grafts for small-diameter vessels. However, they require invasive harvesting and are often unavailable. Synthetic vascular grafts represent an alternative to autologous vessels. These grafts have shown satisfactory long-term results for replacement of large- and medium-diameter arteries, such as the carotid or common femoral artery, but have poor patency rates when applied to small-diameter vessels, such as coronary arteries and arteries below the knee. Considering the limitations of current vascular bypass conduits, a tissue-engineered vascular graft (TEVG) with the ability to grow, remodel, and repair in vivo presents a potential solution for the future of vascular surgery. Here, we review the different methods that research groups have been investigating to create TEVGs in the last decades. We focus on the techniques employed in the manufacturing process of the grafts and categorize the approaches as scaffold-based (synthetic, natural, or hybrid) or self-assembled (cell-sheet, microtissue aggregation and bioprinting). Moreover, we highlight the attempts made so far to translate this new strategy from the bench to the bedside.

The Effect of Pulsatile Flow on bMSC-Derived Endothelial-Like Cells in a Small-Sized Artificial Vessel Made by 3-Dimensional Bioprinting

Replacement of small-sized vessels is still challenging. This study is aimed at investigating the possibility of small-sized artificial vessels made by 3-dimensional bioprinting and the effect of pulsatile flow on bMSC-derived endothelial-like cells. Cells were harvested from rabbit bone marrow and primary cultured with or without growth factors. Endothelial differentiation was confirmed by the Matrigel tube formation assay, Western blot, and qRT-PCR. In addition, embedment of endothelial-like cells in an artificial vessel was made by 3-dimensional bioprinting, and the pulsatile flow was performed. For pumped and nonpumped groups, qRT-PCR was performed on CD31 and VE-cadherin gene expression. Endothelial-like cells showed increased gene expression of CD31 and VE-cadherin, and tube formation is observed at each week. Endothelial-like cells grow well in a small-sized artificial vessel made by 3-dimensional bioprinting and even express higher endothelial cell markers when they undergo pulsatile flow condition. Moreover, the pulsatile flow condition gives a positive effect for cell observation not only on the sodium alginate hydrogel layer but also on the luminal surface of the artificial vessel wall. We have developed an artificial vessel, which is a mixture of cells and carriers using a 3-dimensional bioprinting method, and applied pulsatile flow using a peristaltic pump, and we also demonstrated cell growth and differentiation into endothelial cells. This study suggests guidelines regarding a small-sized artificial vessel in the field of tissue engineering.

Tissue engineered vascular grafts for pediatric cardiac surgery

New technologies and science have contributed to improved surgical outcomes in patients with congenital cardiovascular diseases. However, current materials display shortcomings, such as risk of infection and lack of growth capacity when applied to the pediatric patient population. Tissue engineering has the potential to address these limitations as the ideal tissue engineered vascular graft (TEVG) would be durable, biocompatible, nonthrombogenic, and ultimately remodel into native tissue. The traditional TEVG paradigm consists of a scaffold, cell source, and the integration of the scaffold and cells via seeding. The subsequent remodeling process is driven by cellular adhesion and proliferation, as well as, biochemical and mechanical signaling. Clinical trials have displayed encouraging results, but graft stenosis is observed as a frequent complication. Recent investigations have suggested that a host's immune response plays a vital role in neotissue formation. Current and future studies will focus on modulating host immunity as a means of reducing the incidence of stenosis.

Tissue Engineering Under Microgravity Conditions-Use of Stem Cells and Specialized Cells

Experimental cell research studying three-dimensional (3D) tissues in space and on Earth using new techniques to simulate microgravity is currently a hot topic in Gravitational Biology and Biomedicine. This review will focus on the current knowledge of the use of stem cells and specialized cells for tissue engineering under simulated microgravity conditions. We will report on recent advancements in the ability to construct 3D aggregates from various cell types using devices originally created to prepare for spaceflights such as the random positioning machine (RPM), the clinostat, or the NASA-developed rotating wall vessel (RWV) bioreactor, to engineer various tissues such as preliminary vessels, eye tissue, bone, cartilage, multicellular cancer spheroids, and others from different cells. In addition, stem cells had been investigated under microgravity for the purpose to engineer adipose tissue, cartilage, or bone. Recent publications have discussed different changes of stem cells when exposed to microgravity and the relevant pathways involved in these biological processes. Tissue engineering in microgravity is a new technique to produce organoids, spheroids, or tissues with and without scaffolds. These 3D aggregates can be used for drug testing studies or for coculture models. Multicellular tumor spheroids may be interesting for radiation experiments in the future and to reduce the need for in vivo experiments. Current achievements using cells from patients engineered on the RWV or on the RPM represent an important step in the advancement of techniques that may be applied in translational Regenerative Medicine.

Generation of human umbilical cord vein CD146+ perivascular cell origined three-dimensional vascular construct

Small-diameter vascular grafts are needed for the treatment of coronary artery diseases in the case of limited accessibility of the autologous vessels. Synthetic scaffolds have many disadvantages so in recent years vascular constructs (VCs) made from cellularized natural scaffolds was seen to be very promising but number of studies comprising this area is very limited. In our study, our aim is to generate fully natural triple-layered VC that constitutes all the layers of blood vessel with vascular cells. CD146+ perivascular cells (PCs) were isolated from human umbilical cord vein (HUCV) and differentiated into smooth muscle cells (SMCs) and fibroblasts. They were then combined with collagen type I/elastin/dermatan sulfate and collagen type I/fibrin to form tunica media and tunica adventitia respectively. HUCV endothelial cells (ECs) were seeded on the construct by cell sheet engineering method after fibronectin and heparin coating. Characterization of the VC was performed by immunolabeling, histochemical staining and electron microscopy (SEM and TEM). Differentiated cells were identified by means of immunofluorescent (IF) labeling. SEM and TEM analysis of VCs revealed the presence of three histologic tunicae. Collagen and elastic fibers were observed within the ECM by histochemical staining. The vascular endothelial growth factor receptor expressing ECs in tunica intima; α-SMA expressing SMCs in tunica media and; the tenascin expressing fibroblasts in tunica adventitia were detected by IF labeling. In conclusion, by combining natural scaffolds and vascular cells differentiated from CD146+ PCs, VCs can be generated layer by layer. This study will provide a preliminary blood vessel model for generation of fully natural small-diameter vascular grafts.

[Stem cell-based strategies in vascular surgery]

Critical chronic ischemia in patients with underlying arterial occlusive disease requires vascular reconstructive surgery. The limited supply of suitable small-diameter autologous vascular grafts in many patients and obvious disadvantages of synthetic bypass material demand the development of clinically usable tissue-engineered blood vessel substitutes. Despite substantial progress in the field over the last two decades, their implementation into the clinical routine has been challenging. The limited replicative life span of human adult vascular cells and their slow rate of collagenous matrix production in vitro have posed important problems in the development of mechanically robust and biologically functional engineered grafts. With recent advances in stem cell research, new cell sources for vascular tissue engineering have become available. In particular, the discovery of human induced pluripotent stem (iPS) cells derived from adult differentiated cells, as well as of human multipotent adult mesenchymal stem cells without gene modification requirements and related safety concerns, may advance the development of novel autologous cell-based tissue engineering approaches. Here we discuss recent developments in the field of vascular progenitor cells and opportunities and challenges for the clinical translation of stem cell-engineered vascular tissue substitutes.

Engineering Vessels as Good as New?

Blood vessels convey essential nutrients to end organs, and when diseased, they must be replaced or bypassed. Traditionally plastic and synthetic materials have been used but are susceptible to thrombosis, stenosis, and poor patency rates. A recent report in Science Translational Medicine describes a decellularized matrix grown in vitro from commercially sourced fibroblasts that can be used as a vascular graft. Fibroblasts are grown for several weeks on a fibrin scaffold, laying down a collagen layer. After decellularization and transplantation as an arteriovenous fistula, this group showed that grafts remained patent for several weeks. The lack of cellular material in this graft at the time of transplantation reduced the risk of immune rejection. The matrix laid down by the fibroblasts can serve as a scaffold for recipient cells to colonize after implantation, but also provides structural support for arterial blood flow. Other tissue-engineered grafts of decellularized matrices have recently been tested in clinical trial. For these strategies, the cell type, scaffold material, and culture conditions are key components that dictate not only the type and quality of the end product, but also allow standardization and quality control necessary for widespread translation into clinical use. These off-the-shelf decellularized products may be the first in a new generation of therapies for patients with cardiovascular disease.

Vascular Tissue Engineering: Progress, Challenges, and Clinical Promise

Although the clinical demand for bioengineered blood vessels continues to rise, current options for vascular conduits remain limited. The synergistic combination of emerging advances in tissue fabrication and stem cell engineering promises new strategies for engineering autologous blood vessels that recapitulate not only the mechanical properties of native vessels but also their biological function. Here we explore recent bioengineering advances in creating functional blood macro and microvessels, particularly featuring stem cells as a seed source. We also highlight progress in integrating engineered vascular tissues with the host after implantation as well as the exciting pre-clinical and clinical applications of this technology.

Degradation and erosion mechanisms of bioresorbable porous acellular vascular grafts: an in vitro investigation

A fundamental mechanism of in situ tissue regeneration from biodegradable synthetic acellular vascular grafts is the effective interplay between graft degradation, erosion and the production of extracellular matrix. In order to understand this crucial process of graft erosion and degradation, we conducted an in vitro investigation of grafts (n = 4 at days 1, 4, 7, 10 each) exposed to enzymatic degradation. Herein, we provide constitutive relationships for mass loss and mechanical properties based on much-needed experimental data. Furthermore, we formulate a mathematical model to provide a physics-based framework for understanding graft erosion. A novel finding is that despite their porous nature, grafts lost mass exponentially via surface erosion demonstrating a 20% reduction in outer diameter and no significant change in apparent density. A diffusion based, concentration gradient-driven mechanistic model of mass loss through surface erosion was introduced which can be extended to an in vivo setting through the use of two degradation parameters. Furthermore, notably, mechanical properties of degrading grafts did not scale with mass loss. Thus, we introduced a damage function scaling a neo-Hookean model to describe mechanical properties of the degrading graft; a refinement to existing mass-dependent growth and remodelling (G&R) models. This framework can be used to improve accuracy of well-established G&R theories in biomechanics; tools that predict evolving structure-function relationships of neotissues and guide graft design.

Viscoelastic properties of multi-layered cellularized vascular tissues fabricated from collagen gel

Since collagen is one of the major extracellular matrix components in vascular tissues, its use for vascular tissue engineering has several advantages. However, collagen extraction and processing for tissue engineering application alters its structure. As a result, collagen-based vascular constructs show poor mechanical properties compared to native tissues. In this work, multi-layer (single, double, and triple) vascular tissue constructs were engineered from porcine smooth muscle cells (PSMCs) entrapped in collagen gel by concentrically and sequentially layering after compaction of the previous layer(s). The engineered tissues were matured for either 14 or 21 days to allow the collagen gel to remodel before viscoelasticity, compliance, histological, and protein expression studies were conducted. While there was no significant difference upon addition of the different layers on the elastic modulus (p > .05), the viscous modulus of the single layer construct was significantly lower than the double and triple layer constructs (p < .05). Increasing the number of layers of the cellularized collagen construct increased the wall thickness and the viscous modulus of the construct. Furthermore, the cellularized single-layer construct had a relatively high compliance, but the double and triple layer constructs had compliance values comparable to both engineered vessels and native vessels. PSMCs were uniformly distributed throughout the cross-section and expressed the anticipated marker proteins smooth muscle-α actin, calponin, and smooth muscle myosin heavy chain. Taken together, this study demonstrated the viscoelastic responsiveness of multi-layer collagen-gel based vascular tissues.

Historical Perspective and Future Direction of Blood Vessel Developments

Over the past 40 years, remarkable advances have been made in our understanding of successful blood vessel regeneration, starting with the failures of early tissue-engineered vascular grafts designed using isolated components or molecules, such as collagen gels. The vascular tissue engineers are today better educated and have steered ongoing research developments toward clinical developments of more complete vascular grafts that replicate the multitude of specialized arterial aspects required for function.

Recent Progress in Vascular Tissue-Engineered Blood Vessels

Cardiovascular disease is the number one cause of death in the U.S and results in the loss of approximately one million lives and more than 400 billion U.S. dollars for treatments every year. Recently, tissue engineered blood vessels have been studied and developed as promising replacements for treatment with autologous veins. Here, we summarize the cell sources and methods to make tissue-engineered blood vessels (TEBVs), the recent progress in TEBV related research, and also the recent progress in TEBV related clinical studies.

Triton X-100 combines with chymotrypsin: A more promising protocol to prepare decellularized porcine carotid arteries

BACKGROUND

Morbidity and mortality of cardiovascular diseases are increasing in recent years. To solve these problems, vascular transplantation has become a common approach. Decellularization has been a hot spot of tissue engineering to prepare vessel substitutes for vascular transplantation. However, there is no established canonical protocol for decellularization thus far.

OBJECTIVE

To further understand the decellularization effect of decellularization protocols and the causal relationship between decellularization and mechanical properties.

METHODS

Three decellularization protocols including two chemical protocols based on SDS and Trypsin respectively and a combination of Triton X-100 with chymotrypsin were adopted to obtain decellularized porcine carotid arteries in our study. After decellularization, histological analysis, scanning electron microscopy and mechanical tests were performed to evaluate their efficiency on removing of cellular components, retention of extracellular matrix and influence on mechanical properties.

RESULTS

All these decellularization protocols used in our study were efficient to remove cellular components. However, SDS and trypsin performed more disruptive effect on ECM structure and mechanical properties of native arteries while Triton X-100 combines with chymotrypsin had no significant disruptive effect.

CONCLUSIONS

Compared with decellularization protocols based on SDS and trypsin, Triton X-100 combines with chymotrypsin used in our study may be a more promising protocol to prepare decellularized porcine carotid arteries for vascular tissue engineering applications.