Chapter 15 Device thrombosis and thromboembolism

Recent advancement challenges with synthesis of biocompatible hemodialysis membranes

The focus of this study is to enhance the protein fouling resistance, hydrophilicity, biocompatibility, hemocompatibility and ability of the membranes and to reduce health complications like chronic pulmonary disease, peripheral vascular disease, cerebrovascular disease, and cardiovascular disease after dialysis, which are the great challenges in HD applications. In the current study, the PSF-based dialysis membranes are studied broadly. Significant consideration has also been provided to membrane characteristics (e.g., flowrate coefficient, solute clearance characteristic) and also on commercially available polysulfone HD membranes. PSF has gained a significant share in the development of HD membranes, and continuous improvements are being made in the process to make high flux PSF-based dialysis membranes with enhanced biocompatibility and improved protein resistance ability as the major issue in the development of membranes for HD application is biocompatibility. There has been a great increase in the demand for novel biocompatible membranes that offer the best performances during HD therapy, for example, low oxidative stress and low change ability of blood pressure.

The strategy of modulation blood responses by surface modification with different functional groups on polyester film

A main problem in the design of blood-contacting biomaterials has been the deficiency of a systematic understanding of blood-biomaterial interactions and the strategy to modulate blood responses. In this work, different functional groups including carboxyl (COOH), hydroxyl (OH) and zwitterionic sulfobetaine group (⊕N((CH₃ )₂ )(CH₂ )₃ SO_3-○- , SMDB) were grafted on the poly (butylene terephthalate) (PBT) film to study how the functional groups modulate blood responses and in terms of interaction with the coagulation system, the complement system, and platelets. The results showed protein absorption and platelet adhesion was stronger on the PBT bearing COOH group than PBT films bearing OH and zwitterionic sulfobetaine groups (total protein (μg/cm² ): 32.92 ± 5.89 vs. 22.02 ± 1.44 vs. 19.09 ± 1.59; platelet adhesion (/mm² ): 1,626.7 ± 120.1 vs. 1,395.6 ± 363.3 vs. 1,102.2 ± 373.7), which had a rougher and negatively charged surface, and the coagulation system was inhibited by binding fibrinogen (Fg) and coagulation factors. Meanwhile, PBT-PSMDB showed anticoagulant property and induced platelet activation. As a result, complement formation on these two films were less than PBT bearing OH groups by inhibiting the coagulation system (C3a (ng/ml): 3,745.4 ± 143.9 vs. 3,290.9 ± 249.7 vs. 4,887.9 ± 88.9; C5a (ng/ml): 22.1 ± 2.6 vs. 22.3 ± 1.8 vs. 27.9 ± 2.0). On the other hand, PBT bearing OH groups did not facilitate remarkable platelet adhesion and activation, and had no influence on platelet aggregation, hypotonic shock response, and coagulation system. The above results showed that the blood responses were highly interlinked, and could be modulated by grafting with different functional groups on the biomaterial surfaces. These findings may help identify a strategy to design materials with better hemocompatibility for blood contact, filtration, and purification applications.

A convenient technique for live-cell observation on the surface of polytetrafluoroethylene with a phase-contrast microscope

Phase-contrast microscopy is a convenient technique for live-cell observation on the surface of materials with high optical transmittance. Here, we demonstrate a novel technique to observe living cells on the surface of materials with low optical transmittance, such as polytetrafluoroethylene (PTFE), which are widely used in biomaterials for blood-contacting devices. The surface of a cover glass was coated with a thin PTFE layer with sufficient transmittance, thereby enabling the observation of living cells on the PTFE surface with a phase-contrast microscope.

Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis

PURPOSE

The purpose was to evaluate the safety of anticoagulation in venoarterial extracorporeal membrane oxygenation (VA-ECMO).

DESIGN

We performed a systematic review and meta-analysis using multiple electronic databases. Studies were from 1977 to September 27, 2016. We evaluated the effect of anticoagulation in VA-ECMO on outcomes including major bleeding, thromboembolic events, and in-hospital mortality using a random effects model meta-analysis.

RESULTS

Twenty-six studies (1496 patients) were included. Ten studies only had patients with postcardiotomy shock, 4 studies only included extracorporeal cardiopulmonary resuscitation patients, and 10 studies had a mixture of patients. Most studies (n=17) were low quality with a Newcastle-Ottawa Scale score ≤5. The summary prevalence of major bleeding was 27% (95% confidence interval [CI], 18%-35%), with considerable between-study heterogeneity (I²=91%). Major bleeding requiring reoperation was the most common bleeding event. The summary prevalence of thromboembolic events was 8% (95% CI, 4%-13%; I²=83%). Limb ischemia, circuit-related clotting, and stroke were the most commonly reported events. The summary prevalence for in-hospital mortality was 59% (95% CI, 52%-67%; I²=78%).

CONCLUSIONS

The optimal targets and strategies for anticoagulation in VA-ECMO are unclear. Evaluation of major bleeding and thromboembolic events is limited by study quality and between-study heterogeneity. Clinical trials are needed to investigate the optimal anticoagulation strategy.

Preparation of water-soluble hyperbranched polyester nanoparticles with sulfonic acid functional groups and their micelles behavior, anticoagulant effect and cytotoxicity

Biocompatibility of nanoparticles has been attracting great interest in the development of nanoscience and nanotechnology. Herein, the aliphatic water-soluble hyperbranched polyester nanoparticles with sulfonic acid functional groups (HBPE-SO3 NPs) were synthesized and characterized. They are amphiphilic polymeric nanoparticles with hydrophobic hyperbranched polyester (HBPE) core and hydrophilic sulfonic acid terminal groups. Based on our observations, we believe there are two forms of HBPE-SO3 NPs in water under different conditions: unimolecular micelles and large multimolecular micelles. The biocompatibility and anticoagulant effect of the HBPE-SO3 NPs were investigated using coagulation tests, hemolysis assay, morphological changes of red blood cells (RBCs), complement and platelet activation detection, and cytotoxicity (MTT). The results confirmed that the sulfonic acid terminal groups can substantially enhance the anticoagulant property of HBPE, and the HBPE-SO3 NPs have the potential to be used in nanomedicine due to their good bioproperties.

The influence of device position on the flow within the Penn State 12 cc pediatric ventricular assist device

Ventricular assist devices are a commonly used heart failure therapy for adult patients as bridge-to-transplant or bridge-to-recovery tools. The application of adult ventricular assist devices in pediatric patients has led to increased thrombotic events. Therefore, we have been developing a pediatric ventricular assist device (PVAD), the Penn State 12 cc PVAD. It is designed for patients with a body weight of 5-15 kg and has a stroke volume of 12 cc. Clot formation is the major concern. It is correlated to the coagulability of blood, the blood contacting materials and the fluid dynamics within the system. The intent is for the PVAD to be a long term therapy. Therefore, the system may be oriented in different positions according to the patient's behavior. This study evaluates for the first time the impact of position on the flow patterns within the Penn State 12 cc PVAD, which may help to improve the PVAD design concerning chamber and ports geometries. The fluid dynamics are visualized by particle image velocimetry. The evaluation is based on inlet jet behavior and calculated wall shear rates. Vertical and horizontal model orientations are compared, both with a beat rate of 75, outlet pressures of 90/60 mm Hg and a flow rate of 1.3 l/min. The results show a significant change of the inlet jet behavior and the development of a rotational flow pattern. Vertically, the inlet jet is strong along the wall. It initiates a rotational flow pattern with a wandering axis of rotation. In contrast, the horizontal model orientation results show a weaker inlet jet along the wall with a nearly constant center of rotation location, which can be correlated to a higher risk of thrombotic events. In addition, high speed videography illustrates differences in the diaphragm motion during diastole. Diaphragm opening trajectories measurements determine no significant impact of the density of the blood analog fluids. Hence, the results correlate to human blood.

Synthesis of Nitric Oxide-Releasing Polyurethanes with S-Nitrosothiol-Containing Hard and Soft Segments

Nitric oxide (NO)-releasing polyurethanes capable of releasing up to 0.20 μmol NO cm(-2) were synthesized by incorporating active S-nitrosothiol functionalities into hard and soft segment domains using thiol group protection and post-polymerization modifications, respectively. The nitrosothiol position within the hard and soft segment domains of the polyurethanes impacted both the total NO release and NO release kinetics. The NO storage and release properties were correlated to both chain extender modification and ensuing phase miscibility of the polyurethanes. Thorough material characterization is provided to examine the effects of hard and soft segment modifications on the resultant polyurethane properties.

A parametric study of valve orientation on the flow patterns of the Penn State pulsatile pediatric ventricular assist device

Because of the shortage of organs for transplant in pediatric patients with end-stage heart failure, Penn State is developing a pneumatically driven 12 cc pulsatile pediatric ventricular assist device (PVAD). A major concern is the flow field changes related to the volume decrease and its effect on device thrombogenicity. Previous studies of similar devices have shown that changes in the orientation of the inlet valve can lead to improvement in the flow field. Herein, the fluid dynamic effects of orientation changes at both the inlet and outlet valves are studied. Using two-dimensional particle image velocimetry, we examine the flow field in vitro using an acrylic model of the PVAD in a mock circulatory loop. Regardless of valve orientation, the overall flow pattern inside the PVAD remains similar, but important differences were seen locally in the wall shear rates, which is notable because shear rates >500 s may prevent thrombus formation. As the inlet valve was rotated toward the fluid side of the PVAD, we observed an increase in inlet jet velocity and wall shear rates along the inlet port wall. A corresponding rotation of the outlet valve increases the wall shear rate along the outer wall near the device outlet. Wall shear rates were all higher when both valves were rotated toward the fluid side of the device, with the best rates found at orientations of +15 degrees for both the inlet and outlet valves. Overall, orientations of +15 degrees or +30 degrees of both the inlet and outlet valve resulted in an increase in wall shear rates and could aid in the reduction of thrombus formation inside the PVAD.

Current Strategies in Cardiovascular Biomaterial Functionalization

Prevention of the coagulation cascade and platelet activation is the foremost demand for biomaterials in contact with blood. In this review we describe the underlying mechanisms of these processes and offer the current state of antithrombotic strategies. We give an overview of methods to prevent protein and platelet adhesion, as well as techniques to immobilize biochemically active molecules on biomaterial surfaces. Finally, recent strategies in biofunctionalization by endothelial cell seeding as well as their possible clinical applications are discussed.

Biomimetic fluorocarbon surfactant polymers reduce platelet adhesion on PTFE/ePTFE surfaces

We describe a series of fluorocarbon surfactant polymers designed as surface-modifying agents for improving the thrombogenicity of ePTFE vascular graft materials by the reduction of platelet adhesion. The surfactant polymers consist of a poly(vinyl amine) backbone with pendent dextran and perfluoroundecanoyl branches. Surface modification is accomplished by a simple dip-coating process in which surfactant polymers undergo spontaneous surface-induced adsorption and assembly on PTFE/ePTFE surface. The adhesion stability of the surfactant polymer on PTFE was examined under dynamic shear conditions in PBS and human whole blood with a rotating disk system. Fluorocarbon surfactant polymer coatings with three different dextran to perfluorocarbon ratios (1:0.5, 1:1 and 1:2) were compared in the context of platelet adhesion on PTFE/ePTFE surface under dynamic flow conditions. Suppression of platelet adhesion was achieved for all three coated surfaces over the shear-stress range of 0-75 dyn/cm2 in platelet-rich plasma (PRP) or human whole blood. The effectiveness depended on the surfactant polymer composition such that platelet adhesion on coated surfaces decreased significantly with increasing fluorocarbon branch density at 0 dyn/cm2. Our results suggest that fluorocarbon surfactant polymers can effectively suppress platelet adhesion and demonstrate the potential application of the fluorocarbon surfactant polymers as non-thrombogenic coatings for ePTFE vascular grafts.

Interaction of human plasma fibrinogen with commercially pure titanium as studied with atomic force microscopy and X-ray photoelectron spectroscopy

The surface of a biomaterial interacts with the body fluid upon implantation in the human body. The biocompatibility of a material is strongly influenced by the adsorption of proteins onto the surface. Titanium is frequently used as a biomaterial for implants in orthopedics and cardiovascular devices. Understanding the biocompatibility is very important to improve implants. The surface chemistry of an implant material and its influence on the interaction with body fluid is crucial in that perspective. The main goal of this study was to investigate the conformation of human plasma fibrinogen (HPF) adsorbed on commercially pure titanium (CP Ti) on a molecular level by means of ex situ atomic force microscopy (AFM). With X-ray photoelectron spectroscopy combined with argon ion beam depth profiling, it was shown that the oxide layer present at the surface was mainly composed of TiO2, with a small percentage of Ti2O3. Ex situ AFM imaging showed the conformation of HPF on CP Ti. Single molecules and aggregates of fibrinogen were observed. The trinodular structure of single HPF molecules (two spherical D domains at the distal ends of the extended molecule and the central spherical E domain) adsorbed onto CP Ti was visualized. Aggregate formation through the connection of the D domains of the HPF molecules was observed on CP Ti. The alphaC domains of HPF were not visible on CP Ti. The ex situ AFM images indicated conformational changes of HPF upon adsorption onto CP Ti. The conformation of the adsorbed HPF molecules was different on mica and titanium. The difference in wettability between both substrates caused a larger spread of the protein on the CP Ti surface and thus resulted in a larger perturbation to the native structure of HPF as compared to mica.

Effects of mechanical valve orifice direction on the flow pattern in a ventricular assist device

We have been developing a pneumatic ventricular assist device (PVAD) system consisting of a diaphragm-type blood pump. The objective of the present study was to evaluate the flow pattern inside the PVAD, which may greatly affect thrombus formation, with respect to the inflow valve-mount orientation. To analyze the change of flow behavior caused by the orifice direction (OD) of the valve, the flow pattern in this pump was visualized. Particle image velocimetry was used as a measurement technique to visualize the flow dynamics. A monoleaflet mechanical valve was mounted in the inlet and outlet ports of the PVAD, which was connected to a mock circulatory loop tester. The OD of the inlet valve was set at six different angles (OD = 0 degrees, 45 degrees, 90 degrees, 135 degrees, 180 degrees, and 270 degrees, where the OD opening toward the diaphragm was defined as 0 degrees ) and the pump rate was fixed at 80 bpm to create a 5.0 l/min flow rate. The main circular flow in the blood pump was affected by the OD of the inlet valve. The observed regional flow velocity was relatively low in the area between the inlet and outlet port roots, and was lowest at an OD of 90 degrees. In contrast, the regional flow velocity in this area was highest at an OD of 135 degrees. The OD is an important factor in optimizing the flow condition in our PVAD in terms of preventing flow stagnation, and the best flow behavior was realized at an OD of 135 degrees.

Nitric Oxide Releasing Polyurethanes with Covalently Linked Diazeniumdiolated Secondary Amines

Two novel strategies for synthesizing stable polyurethanes (PUs) capable of generating bioactive nitric oxide (NO) are described. The methods rely on covalently attaching diazeniumdiolate (N(2)O(2)(-)) groups onto secondary amine nitrogens at various positions within the polymer chain such that, when in contact with water or physiological fluids, only the two molecules of NO available from each diazeniumdiolate moiety are released into the surrounding medium, with potential byproducts remaining covalently bound to the matrix. Extensive analysis of the NO(x)() products released from the polymers was employed to develop appropriate strategies to better stabilize the diazeniumdiolate-based polymer structures. In one approach, diazeniumdiolate groups are attached to secondary amino nitrogens of alkane diamines inserted within the diol chain extender of a PU material. Oxidative loss of NO was minimized by blending the polymer with a biocompatible, relatively nonnucleophilic salt before exposing solutions of the polymer to NO during the diazeniumdiolation step. Fluxes of molecular NO from such materials during immersion in physiological buffer reached levels as high as 19 pmol x cm(-2) x s(-1) with a total recovery of 21 nmol of NO/mg of PU. A second general synthetic strategy involved omega-haloalkylating the urethane nitrogens and then displacing the halide from the resulting polymer with a nucleophilic polyamine to form a PU with pendent amino groups suitable for diazeniumdiolation. Commercially available Pellethane 2363-80AE that was bromobutylated and then reacted with diethylenetriamine and further exposed to gaseous NO proved stable in solid form for several months, but released NO with a total recovery of 17 nmol/mg upon immersion in physiological buffer. This material showed an initial NO flux of 14 pmol x cm(-2) x s(-1) when immersed in pH 7.4 buffer at 37 degrees C, with gradually decreasing but still observable fluxes for up to 6 days.

Biomaterial-associated thrombosis: roles of coagulation factors, complement, platelets and leukocytes

Our failure to produce truly non-thrombogenic materials may reflect a failure to fully understand the mechanisms of biomaterial-associated thrombosis. The community has focused on minimizing coagulation or minimizing platelet adhesion and activation. We have infrequently considered the interactions between the two although we are generally familiar with these interactions. However, we have rarely considered in the context of biomaterial-associated thrombosis the other major players in blood: complement and leukocytes. Biomaterials are known agonists of complement and leukocyte activation, but this is frequently studied only in the context of inflammation. For us, thrombosis is a special case of inflammation. Here we summarize current perspectives on all four of these components in thrombosis and with biomaterials and cardiovascular devices. We also briefly highlight a few features of biomaterial-associated thrombosis that are not often considered in the biomaterials literature: The importance of tissue factor and the extrinsic coagulation system. Complement activation as a prelude to platelet activation and its role in thrombosis. The role of leukocytes in thrombin formation. The differing time scales of these contributions.

Assessment of bovine platelet life span with biotinylation and flow cytometry

Reduced platelet life span is associated with the implantation of a variety of cardiovascular devices and may be used as a gauge of device biocompatibility. In the bovine model, platelet life span has previously been assessed with radioisotope labeling of removed platelets followed by reinjection and periodic gamma counting of blood samples. We report here the use of protein-reactive biotin (sulfo-N-hydroxysuccinimido [NHS]-biotin) as an alternative to radioisotope techniques whereby reinjected biotinylated platelets are subsequently detected in blood samples using phycoerythrin-streptavidin and flow cytometric techniques. Platelet life span was quantified in a normal calf (4.9 days) and in a calf prior to (6.1 days) and following (3.1 days) implantation of a Nimbus Axial Flow Pump ventricular assist device. The assessment of bovine platelet life span with biotinylation and flow cytometry avoids the technical, regulatory, and safety considerations associated with radioisotope usage and appears readily amenable to application in cardiovascular device testing.

Blood and tissue compatibility of modified polyester: thrombosis, inflammation, and healing

Poly(ethylene terephthalate) (PET) has been reported in literature to be moderately inflammatory and thrombogenic. To moderate the inflammatory response, PET fabric was surface modified by either Fluoropassiv fluoropolymer (FC), or an RGD-containing peptide (RGD). Samples were subsequently autoclave sterilized and implanted subcutaneously in Sprague Dawley rats for 2 to 4 weeks. Retrieved samples were evaluated histopathologically for indications of material toxicity and healing. Minimal acute or chronic inflammation was associated with the fabrics after 2 and 4 week implant duration. However, fibroblast proliferation into FC modified fabric (PET/FC) was less than that into unmodified (PET) and RGD modified fabric (PET/RGD) after 4 weeks, suggesting that FC modification of PET may inhibit excessive tissue growth. Additional samples of modified and unmodified fabrics were placed in stainless steel mesh cages, which were then implanted subcutaneously for 4 weeks. Cellular exudate was extracted weekly and cell concentrations within the exudate measured. Total leukocyte count (TLC) (reflective of local inflammation) at 1 week for PET/RGD was greater than that for PET/FC and PET. TLCs after 4 week implant decreased for all sample groups. In a separate experiment, PET vascular grafts surface modified by either FC or RGD were contacted 1 h with blood using the baboon arteriovenous (AV) shunt model of thrombosis in both the presence and absence of heparin. Accumulation of 111In labeled platelets (reflective of thrombus accumulation) upon grafts was less in the presence of heparin (effect significant at p = 1.2 x 10(-6), two-way ANOVA). Accumulation (in the presence of heparin) upon PET/RGD was less (p = 0.19), and upon PET/FC significantly less (p = 0.016) than that upon the unmodified PET control, suggesting that FC modification of PET may inhibit thrombus accumulation.

Platelet adhesion onto artificial surfaces: inhibition by benzamidine, pentamidine, and pyridoxal-5-phosphate as demonstrated by flow cytometric quantification of platelet adhesion to microspheres

An appreciable effort is directed toward designing strategies to minimize platelet interactions with artificial surfaces, because their reactivity is thought to promote thrombus formation and lead to materials failure. Although platelet glycoprotein Ib/IX (GPIb/IX) and glycoprotein IIb/IIa (GPIIb/IIIa) receptors are thought to mediate adhesion, whether GPIIb/IIIa receptors are activated and how this might occur are largely unknown and are the focus of this article. There are a few ways, other than thrombin generation, that blood contact with artificial surfaces can lead to GPIIb/IIIa activation. Complement activation can lead to products capable of activating platelets (C1q, C5b-9), and contact between platelet CD32 (FcgammaRII) receptors and immobilized immunoglobulin G could also activate platelets. In this article the potential role of these processes was evaluated by using various inhibitors in a microsphere-based platelet adhesion immunoassay. Polystyrene microspheres (10 microm) were incubated in platelet-rich plasma before flow cytometric analysis of beads for adherent platelets. The data eliminated occupancy of the FcgammaRII receptor (by use of IV.3 blocking antibody), C5b-9 production (by use of sCR1), and the indirect action of factor XIIa on complement components (by use of corn trypsin inhibitor) as playing roles in supporting platelet adhesion. Agents directed against the first complement component (benzamidine, pentamidine, pyridoxal-5-phosphate) were effective inhibitors of platelet adhesion and were also demonstrated to inhibit SC5b-9 and C3d levels on the bead surface after serum incubations. Because these agents are not highly specific, it can not be concluded that C1q is a mediator of adhesion. These agents were also demonstrated to inhibit fluorescein isothiocyanate-fibrinogen binding to activated washed platelets, therefore indicating that fibrinogen receptor expression is a requirement for platelet adhesion.

Material-induced up-regulation of leukocyte CD11b during whole blood contact: material differences and a role for complement

Material-induced thrombogenicity is in part a consequence of leukocyte activation. To evaluate and compare material-induced platelet damage, we have expanded our in vitro flow cytometric immunoassay to include assessment of leukocyte activation. We have used a very simple system whereby fresh, heparinized whole blood contacts materials for 1 h at 37 degrees C under low shear. Unlike other tests that focus on adherent leukocytes, this assay evaluates the leukocytes in the whole blood drained from the tube (1.57 mm internal diameter, 25 cm length) after material contact. We demonstrate that whole blood contact with a polyvinyl alcohol (PVA) hydrogel surface leads to a twofold up-regulation in CD11b surface expression of all monocytes and neutrophils. The activation is metal-ion dependent and highly material dependent in that blood contact with polyethylene and Silastic surface leads to minimal activation. The shedding of L-selection as a marker of leukocyte activation was found to be unsuitable in our assay given it ease of shedding in resting heparinized whole blood. Further, plasma levels of complement components Bb and sC5b-9 (ELISA assays) were significantly elevated only after blood contact with PVA hydrogel surfaces (9.4 micrograms/mL sC5b-9 and 9.6 micrograms/mL Bb). Use of recombinant soluble human CR1 (sCR1) to inhibit the action of the C3 and C5 convertases completely inhibited sC5b-9 levels in whole blood after contact with PVA hydrogel surfaces and inhibited CD11b up-regulation by over 70%, suggesting that material-induced leukocyte activation is partially mediated by C5a production.

Nitric oxide-releasing polymers containing the [N(O)NO]- group

Ions of structure X[N(O)NO]- display broad-spectrum pharmacological activity that correlates with the rate and extent of their spontaneous, first-order decomposition to nitric oxide when dissolved. We report incorporation of this functional group into polymeric matrices that can be used for altering the time course of nitric oxide release and/or targeting it to tissues with which the polymers are in physical contact. Structural types prepared include those in which the [N(O)NO]- group is attached to heteroatoms in low molecular weight species that are noncovalently distributed throughout the polymeric matrix, in groupings pendant to the polymer backbone, and in the polymer backbone itself. They range in physical form from films that can be coated onto other surfaces to microspheres, gels, powders, and moldable resins. Chemiluminescence measurements confirm that polymers to which the [N(O)NO]- group is attached can serve as localized sources of nitric oxide, with one prototype providing sustained NO release for 5 weeks in pH 7.4 buffer at 37 degrees C. The latter composition, a cross-linked poly-(ethylenimine) that had been exposed to NO, inhibited the in vitro proliferation of rat aorta smooth muscle cells when added as a powder to the culture medium and showed potent antiplatelet activity when coated on a normally thrombogenic vascular graft situated in an arteriovenous shunt in a baboon's circulatory system. The results suggest that polymers containing the [N(O)NO]- functional group may hold considerable promise for a variety of biomedical applications in which local delivery of NO is desired.