Evolution of covered stents in the contemporary era: clinical application, materials and manufacturing strategies using nanotechnology

Treatment of Traumatic Direct Carotid-Cavernous Fistula with a BeGraft-Covered Stent

The widely accepted option for treating traumatic direct carotid-cavernous fistula (dCCF) has been endovascular treatment using detachable balloons, coils, or embolic agents. Covered stent deployment has been applied by a few operators and has shown promising results. This is a retrospective study on patients with dCCF treated by an endovascular approach using BeGraft, a covered stent. In 4 cases, this device was successfully deployed without any complications. Immediate complete occlusion was achieved in 3 patients (75%) after deployment of the covered stents. One patient required transvenous coiling for occlusion of the remaining endoleak. Follow-up imaging demonstrated 100% fistula occlusion with complete internal carotid artery patency. No early or late complications occurred following treatment. In conclusion, the BeGraft-covered stent could be a promising safe and effective alternative option for the endovascular treatment of dCCF.

Nanotechnology: The Future for Diagnostic and Therapeutic Intervention in Cardiovascular Diseases is Here

With advances in technology and medicine over the last 3 decades, cardiovascular medicine has evolved tremendously. Nanotechnology provides a promising future in personalized precision medicine. In this review, we delve into the current and prospective applications of nanotechnology and nanoparticles in cardiology. Nanotechnology has allowed for point-of-care testing such as high-sensitivity troponins, as well as more precise cardiac imaging. This review is focused on 3 diseases within cardiology: coronary artery disease, heart failure, and valvular heart disease. The use of nanoparticles in coronary stents has shown success in preventing in-stent thrombosis, as well as using nanosized drug delivery medications to prevent neointimal proliferation in a way that spares systemic toxicity. In addition, by using nanoparticles as drug delivery systems, nanotechnology can be utilized in the delivery of goal-directed medical therapy in heart failure patients. It has also been shown to improve cell therapy in this patient population by helping in cell retention of grafts. Finally, the use of nanoparticles in the manufacturing of bioprosthetic valves provides a promising future for the longevity and success of cardiac valve repair and replacement.

Virtual and analytical self-expandable braided stent treatment models

The Flow Diverter is a self-expandable braided stent that has helped improve the effectiveness of cerebral aneurysm treatment during the last decade. The Flow Diverter's efficiency heavily relies on proper decision-making during the pre-operative phase, which is currently based on static measurements that fail to account for vessel or tissue deformation. In the context of providing realistic measurements, a biomechanical computational method is designed to aid physicians in predicting patient-specific treatment outcomes. The method integrates virtual and analytical treatment models, validated against experimental mechanical tests, and two patient treatment outcomes. In the case of both patients, deployed stent length was one of the validated result parameters, which displayed an error inferior to 1.5% for the virtual and analytical models. These results indicated both models' accuracy. However, the analytical model provided more accurate results with a 0.3% error while requiring a lower computational cost for length prediction. This computational method can offer designing and testing platforms for predicting possible intervention-related complications, patient-specific medical device designs, and pre-operative planning to automate interventional procedures.

Endovascular tools for vascular access stenosis: Flow-chart proposal

Stenosis represents the most relevant arteriovenous fistula (AVF) pathology and can affects the entire conduit forming the fistula, from afferent artery to central venous vessels. Correction of vascular access stenosis significantly affects the survival and quality of life for end stage renal disease patients (ESRD) dependent on hemodialysis. Guidelines consider the procedure of percutaneous transluminal angioplasty (PTA) relevant for the primary treatment of these lesions with excellent results in restoring AVF immediately at the end of the procedure. From first AVF angioplasty in 1981 to now, wide scientific innovation has led to development of new devices, composed by different materials and technologies, specific for the site and the type of stenosis to be treated, able to manage resistant stenotic lesion and to reduce stenosis recurrences. International guidelines do not clearly specify all treatment possibilities in the individual case. In this review the authors want to provide specific information on most used devices for stenosis treatment based on literature evidence, showing when and where to use the various tools available with flow-chart treatment proposal.

Thermoplastic polyurethane/POSS nanohybrids: Synthesis, morphology, and biological properties

Recent studies show good osteoinductive properties of polyurethanes modified with polyhedral oligomeric silsesquioxanes (POSS). In this work, three types of POSS; propanediolisobutyl-POSS (PHI-POSS), disilanolisobutyl-POSS (DSI-POSS), and octahydroxybutyl-POSS (OCTA-POSS) were chemically incorporated into linear polyurethane based on an aliphatic isocyanate, hexamethylene diisocyanate (HDI), to obtain new nanohybrid PU-POSS materials. The full conversion of POSS was confirmed by Fourier transform infrared spectroscopy (FTIR-ATR) spectra of the model reactions with pure HDI. The materials obtained were investigated by FTIR, SEM-EDS, and DSC. The DSC studies showed the thermoplasticity of the obtained materials and apparently good recovery. 30-day immersion in SBF (simulated body fluid) revealed an increase in the rate of deposition of hydroxyapatite (HAp) for the highest POSS loadings, resulting in thick layers of hydroxyapatite (~60-40 μm), and the Ca/P ratio 1.67 (even 1.785). The structure and properties of the inorganic layer depend on the type of POSS, the number of hard segments, and those containing POSS, which can be tailored by changing the HDI/poly(tetramethylene glycol) (PTMG) ratio. Furthermore, the obtained composites revealed good biocompatibility, as confirmed by cytotoxicity tests conducted on two cell lines; normal human dermal fibroblasts (NHDF) and primary human osteoblasts (HOB). Adherent cells seeded on the tested materials showed viability even after a 48-h incubation. After this time, the population of viable, and proliferating cells exceeded 90%. Bioimaging studies have shown the fibroblast and osteoblast cells were well attached to the surface of the tested materials.

A dual-mode fiber-shaped flexible capacitive strain sensor fabricated by direct ink writing technology for wearable and implantable health monitoring applications

Flexible fiber-shaped strain sensors show tremendous potential in wearable health monitoring and human‒machine interactions due to their compatibility with everyday clothing. However, the conductive and sensitive materials generated by traditional manufacturing methods to fabricate fiber-shaped strain sensors, including sequential coating and solution extrusion, exhibit limited stretchability, resulting in a limited stretch range and potential interface delamination. To address this issue, we fabricate a fiber-shaped flexible capacitive strain sensor (FSFCSS) by direct ink writing technology. Through this technology, we print parallel helical Ag electrodes on the surface of TPU tube fibers and encapsulate them with a high dielectric material BTO@Ecoflex, endowing FSFCSS with excellent dual-mode sensing performance. The FSFCSS can sense dual-model strain, namely, axial tensile strain and radial expansion strain. For axial tensile strain sensing, FSFCSS exhibits a wide detection range of 178%, a significant sensitivity of 0.924, a low detection limit of 0.6%, a low hysteresis coefficient of 1.44%, and outstanding mechanical stability. For radial expansion strain sensing, FSFCSS demonstrates a sensitivity of 0.00086 mmHg-1 and exhibits excellent responsiveness to static and dynamic expansion strain. Furthermore, FSFCSS was combined with a portable data acquisition circuit board for the acquisition of physiological signals and human‒machine interaction in a wearable wireless sensing system. To measure blood pressure and heart rate, FSFCSS was combined with a printed RF coil in series to fabricate a wireless hemodynamic sensor. This work enables simultaneous application in wearable and implantable health monitoring, thereby advancing the development of smart textiles.

Expanded Polytetrafluoroethylene Membranes for Vascular Stent Coating: Manufacturing, Biomedical and Surgical Applications, Innovations and Case Reports

Coated stents are defined as innovative stents surrounded by a thin polymer membrane based on polytetrafluoroethylene (PTFE)useful in the treatment of numerous vascular pathologies. Endovascular methodology involves the use of such devices to restore blood flow in small-, medium- and large-calibre arteries, both centrally and peripherally. These membranes cross the stent struts and act as a physical barrier to block the growth of intimal tissue in the lumen, preventing so-called intimal hyperplasia and late stent thrombosis. PTFE for vascular applications is known as expanded polytetrafluoroethylene (e-PTFE) and it can be rolled up to form a thin multilayer membrane expandable by 4 to 5 times its original diameter. This membrane plays an important role in initiating the restenotic process because wrapped graft stent could be used as the treatment option for trauma devices during emergency situations and to treat a number of pathological vascular disease. In this review, we will investigate the multidisciplinary techniques used for the production of e-PTFE membranes, the advantages and disadvantages of their use, the innovations and the results in biomedical and surgery field when used to cover graft stents.

Surface Properties of the Polyethylene Terephthalate (PET) Substrate Modified with the Phospholipid-Polypeptide-Antioxidant Films: Design of Functional Biocoatings

Surface properties of polyethylene terephthalate (PET) coated with the ternary monolayers of the phospholipid 1,2-dioleoyl-sn-glycero-3-phosphocholine (DOPC), the immunosuppressant cyclosporine A (CsA), and the antioxidant lauryl gallate (LG) were examined. The films were deposited, by means of the Langmuir-Blodgett (LB) technique, on activated by air low temperature plasma PET plates (PET_air). Their topography and surface chemistry were determined with the help of atomic force microscopy (AFM) and time-of-flight secondary ion mass spectrometry (TOF-SIMS), respectively, while wettability was evaluated by the contact angle measurements. Then, the surface free energy and its components were calculated from the Lifshitz-van der Waals/Acid-Base (LWAB) approach. The AFM imaging showed that the Langmuir monolayers were transferred effectively and yielded smoothing of the PET_air surface. Mass spectrometry confirmed compatibility of the quantitative and qualitative compositions of the monolayers before and after the transfer onto the substrate. Moreover, the molecular arrangement in the LB films and possible mechanisms of DOPC-CsA-LG interactions were determined. The wettability studies provided information on the type and magnitude of the interactions that can occur between the biocoatings and the liquids imitating different environments. It was found that the changes from open to closed conformation of CsA molecules are driven by the hydrophobic environment ensured by the surrounding DOPC and LG molecules. This process is of significance to drug delivery where the CsA molecules can be released directly from the biomaterial surface by passive diffusion. The obtained results showed that the chosen techniques are complementary for the characterization of the molecular organization of multicomponent LB films at the polymer substrate as well as for designing biocompatible coatings with precisely defined wettability.

The Technological Advancement to Engineer Next-Generation Stent-Grafts: Design, Material, and Fabrication Techniques

Endovascular treatment of aortic disorders has gained wide acceptance due to reduced physiological burden to the patient compared to open surgery, and ongoing stent-graft evolution has made aortic repair an option for patients with more complex anatomies. To date, commercial stent-grafts are typically developed from established production techniques with simple design structures and limited material ranges. Despite the numerous updated versions of stent-grafts by manufacturers, the reoccurrence of device-related complications raises questions about whether the current manfacturing methods are technically able to eliminate these problems. The technology trend to produce efficient medical devices, including stent-grafts and all similar implants, should eventually change direction to advanced manufacturing techniques. It is expected that through recent advancements, especially the emergence of 4D-printing and smart materials, unprecedented features can be defined for cardiovascular medical implants, like shape change and remote battery-free self-monitoring. 4D-printing technology promises adaptive functionality, a highly desirable feature enabling printed cardiovascular implants to physically transform with time to perform a programmed task. This review provides a thorough assessment of the established technologies for existing stent-grafts and provides technical commentaries on known failure modes. They then discuss the future of advanced technologies and the efforts needed to produce next-generation endovascular implants.

In Vitro Degradability, Microstructural Evaluation, and Biocompatibility of Zn-Ti-Cu-Ca-P Alloy

According to the modern era, zinc is one of the best replacements for human bio-implants due to its acceptable degradation, nominal degradable rate, and biocompatibility. However, alloying zinc with other nutrient metals is mandatory to improve the mechanical properties. In this research, Zn-4Ti-4Cu was alloyed with calcium and phosphorous through a powder metallurgical process to make guided bone regeneration (GBR). First, the sintering temperature of the alloy was found with the usage of thermogravimetric analysis (TGA). Tensile and compression tests showed the suitability of the alloy in strength. The microstructural characteristics were provided with EDS and SEM. The different phases of the alloy were detected with X-ray diffraction (XRD). We can clearly depict the precipitates formed and the strengthening mechanism due to titanium addition. An electrochemical corrosion (ECM) test was carried out with simulated body fluid (Hank’s solution) as the electrolyte. Cytotoxicity, biocompatibility, mechanical properties, and corrosion resistance properties were studied and discussed.

Fluorine-containing bio-inert polymers: Roles of intermediate water

Fluorine-containing polymers are used not only in industrial processes but also in medical applications, because they exhibit excellent heat, weather, and chemical resistance. As these polymers are not easily degraded in our body, it is difficult to use them in applications that require antithrombotic properties, such as artificial blood vessels. The material used for medical applications should not only be stable in vivo, but it should also be inert to biomolecules such as proteins or cells. In this review, this property is defined as "bio-inert," and previous studies in this field are summarized. Bio-inert materials are less recognized as foreign substances by proteins or cells in the living body, and they must be covered at interfaces designed with the concept of intermediate water (IW). On the basis of this concept, we present here the current understanding of bio-inertness and unusual blood compatibility found in fluoropolymers used in biomedical applications. IW is the water that interacts with materials with moderate strength and has been quantified by a variety of analytical methods and simulations. For example, by using differential scanning calorimetry (DSC) measurements, IW was defined as water frozen at around -40°C. To consider the role of the IW, quantification methods of the hydration state of polymers are also summarized. These investigations have been conducted independently because of the conflict between hydrophobic fluorine and bio-inert properties that require hydrophilicity. In recent years, not many materials have been developed that incorporate the good points of both aspects, and their properties have seldom been linked to the hydration state. This has been critically performed now. Furthermore, fluorine-containing polymers in medical use are reviewed. Finally, this review also describes the molecular design of the recently reported fluorine-containing bio-inert polymers for controlling their hydration state. STATEMENT OF SIGNIFICANCE: A material covered with a hydration layer known as intermediate water that interacts moderately with other objects is difficult to be recognized as a foreign substance and exhibits bio-inert properties. Fluoropolymers show high durability, but conflict with bio-inert characteristics requiring hydrophilicity as these research studies have been conducted independently. On the other hand, materials that combine the advantages of both hydrophobic and hydrophilic features have been developed recently. Here, we summarize the molecular architecture and analysis methods that control intermediate water and provide a guideline for designing novel fluorine-containing bio-inert materials.

Recent Advances in Polyurethane/POSS Hybrids for Biomedical Applications

Advanced organic-inorganic materials-composites, nanocomposites, and hybrids with various compositions offer unique properties required for biomedical applications. One of the most promising inorganic (nano)additives are polyhedral oligomeric silsesquioxanes (POSS); their biocompatibility, non-toxicity, and phase separation ability that modifies the material porosity are fundamental properties required in modern biomedical applications. When incorporated, chemically or physically, into polyurethane matrices, they substantially change polymer properties, including mechanical properties, surface characteristics, and bioactivity. Hence, this review is dedicated to POSS-PU composites that have recently been developed for applications in the biomedical field. First, different modes of POSS incorporation into PU structure have been presented, then recent developments of PU/POSS hybrids as bio-active composites for scaffolds, cardiovascular stents, valves, and membranes, as well as in bio-imaging and cancer treatment, have been described. Finally, characterization and methods of modification routes of polyurethane-based materials with silsesquioxanes were presented.

A Computational Framework Examining the Mechanical Behaviour of Bare and Polymer-Covered Self-Expanding Laser-Cut Stents

PURPOSE

Polymer covered stents have demonstrated promising clinical outcomes with improved patency rates compared to traditional bare-metal stents. However, little is known on the mechanical implication of stent covering. This study aims to provide insight into the role of a polymeric cover on the biomechanical performance of self-expanding laser-cut stents through a combined experimental-computational approach.

METHODS

Experimental bench top tests were conducted on bare and covered versions of a commercial stent to evaluate the radial, axial and bending response. In parallel, a computational framework with a novel covering strategy was developed that accurately predicts stent mechanical performance. Different stent geometries and polymer materials were also considered to further improve understanding on covered stent mechanics.

RESULTS

Results show that stent covering causes increased initial axial stiffness and up to 60% greater radial resistive force at small crimp diameters as the cover folds and self-contacts. The incorporation of a cover allows stent designs without interconnecting struts, thereby providing improved flexibility without compromising radial force. It was also shown that use of a stiffer PET polymeric covering material caused significant alterations to the radial and axial response, with the initial axial stiffness increasing six-fold and the maximum radial resistive force increasing four-fold compared to a PTFE-PU covered stent.

CONCLUSION

This study demonstrates that stent covering has a substantial effect on the overall stent mechanical performance and highlights the importance of considering the mechanical properties of the combined cover and stent.

A Recombinant Fusion Construct between Human Serum Albumin and NTPDase CD39 Allows Anti-Inflammatory and Anti-Thrombotic Coating of Medical Devices

Medical devices directly exposed to blood are commonly used to treat cardiovascular diseases. However, these devices are associated with inflammatory reactions leading to delayed healing, rejection of foreign material or device-associated thrombus formation. We developed a novel recombinant fusion protein as a new biocompatible coating strategy for medical devices with direct blood contact. We genetically fused human serum albumin (HSA) with ectonucleoside triphosphate diphosphohydrolase-1 (CD39), a promising anti-thrombotic and anti-inflammatory drug candidate. The HSA-CD39 fusion protein is highly functional in degrading ATP and ADP, major pro-inflammatory reagents and platelet agonists. Their enzymatic properties result in the generation of AMP, which is further degraded by CD73 to adenosine, an anti-inflammatory and anti-platelet reagent. HSA-CD39 is functional after lyophilisation, coating and storage of coated materials for up to 8 weeks. HSA-CD39 coating shows promising and stable functionality even after sterilisation and does not hinder endothelialisation of primary human endothelial cells. It shows a high level of haemocompatibility and diminished blood cell adhesion when coated on nitinol stents or polyvinylchloride tubes. In conclusion, we developed a new recombinant fusion protein combining HSA and CD39, and demonstrated that it has potential to reduce thrombotic and inflammatory complications often associated with medical devices directly exposed to blood.

Covered Stent Treatment of an Extracranial Internal Carotid Artery Pseudoaneurysm in a Three Year Old Child with 12 Years of Follow Up: A Case Report

Introduction

Extracranial internal carotid artery (ICA) pseudoaneurysms in children, although uncommon, are life threatening. Covered stents are a good alternative treatment, as they avoid the risk of open surgery and preserve the ICA. Until recently, long term outcomes were unknown.

Report

A three year old boy was hospitalised with an enlarged swelling on the left side of his neck and severe respiratory distress. He had been treated a month prior for a left deep cervical abscess, with bacteriological culture positive for Staphylococcus aureus. Computed tomography angiography (CTA) revealed a large pseudoaneurysm originating from the left ICA, approximately 2 cm above the bifurcation. A balloon expanded covered stent (Jostent Graftmaster; Abbott Vascular, Redwood City, CA, USA) was deployed via a left femoral approach, after selective angiography, to seal the carotid rupture without incident. Control angiography revealed immediate exclusion of the pseudoaneurysm and patent ICA. The bacteriological culture of the residual haematoma was negative. The child was discharged with full recovery and without neurological sequelae, under platelet anti-aggregation. He has been followed up and has remained asymptomatic for 12 years, with CTA confirmed ICA patency, without deformation or evidence of significant restenosis.

Discussion

This is the first report of the long term outcome of a covered stent in a child treated at three years of age, with a 12 year follow up. The good performance of the covered stent in this case reinforces its adoption as a first line option in the treatment of extracranial ICA pseudoaneurysms in children.

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Endovascular treatment is the first choice for carotid pseudoaneurysms in children.

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Covered stents can be an effective and safe option.

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Uneventful long term outcomes.

Numerical modeling of bare and polymer-covered braided stents using torsional and tensile springs connectors

Computational modeling of braided stents using the finite element (FE) method has become an essential tool in the design and development of these medical devices. One of the most challenging issues in such a task is representing in an accurate manner the interaction between the interlacing wires. With the goal of achieving a compromise between accuracy and computational affordability, we propose a new approach consisting in using 1D FE formulations equipped with torsional springs at the crossover points of the wires. In the case of covered braided stents, the model is enriched with a set of tensile springs (defined in the longitudinal direction), aimed at capturing the stiffening effect of the polymeric membrane. The predictive capabilities of the proposed model are evaluated using data of our own experimental tests, as well as data from other tests in the literature. The simulations demonstrate that the proposed model is able to predict the (markedly nonlinear) behavior of stents when subjected to radial and axial cycle loads, with errors at the end of the compression stage ranging from 0.5% to 10% in all cases.

Optimization of a Novel Preferential Covered Stent through Bench Experiments and in Vitro Platelet Activation Studies

Bare metal stenting (BMS) does not adequately address the atheroembolic characteristic of carotid artery stenosis. While simple covered stents (CS) may prevent dislodged fragments of the atherosclerotic plaque from entering the blood stream, they also block blood flow into the major branches of the artery alongside the lesion, which is not desirable. Preferential covered stents (PCS) behave as a covered stent in a tubular part of a vessel but maintain side-branch flow over the bifurcation region by means of slits in the membrane. Stent design, membrane material, and slits configuration are the three main components contributing to stent performance. Optimization of PCS designs was conducted and tested.

METHODS

A newly designed BMS was developed and compared to a commercially available peripheral stent. Two materials (expanded poly(tetrafluoroethylene)) and silicone polyurethane co-polymers (Elast-eon E2A) were used as stent coverings with slits applied using various cutting methods to form the PCS. These PCS samples were tested for physical resilience, flexibility, ability to preserve side-branch flow, slit edge roughness, and platelet activation.

RESULTS

Fabrication of E2A-coated stents required pretreatment of the stent with poly(ethylene glycol) to achieve firm attachment. The newly designed BMS with nine crowns design and larger cell size showed higher flexibility than commercially available stents. A combination of a larger stent cell size, E2A membrane coating, and three slits per stent cell unit configuration resulted in preserved side-branch flow similar to physiological conditions in the flow experiment. Slit edge roughness changed with different cutting methods and laser machine cutting parameters. In vitro studies showed platelet activation was minimal with lower slit edge roughness samples.

CONCLUSION

An optimized PCS prototype was developed consisting of a newly designed stent, E2A membrane, and a three-slit pattern created by specific femtosecond laser cutting.

Development of a Bioactive Polymeric Drug Eluting Coronary Stent Coating Using Electrospraying

Drug-eluting stents are now routinely used in the treatment of acute coronary syndromes caused by coronary artery disease. Whilst the sustained release of anti-proliferative drugs from these devices has greatly reduced the need for repeat revascularisation procedures, this approach is not suitable for all patients and appears to delay regrowth of the endothelium, necessitating the use of prolonged dual anti-platelet therapy. Although the development of more advanced stent platforms and drug coatings has produced modest improvements in performance, these devices have not fully addressed the limitations experienced with their first-generation counterparts. In the present study, we developed a novel stent coating that provides controlled sirolimus release from a bioactive polymer (accelerate™ AT) that has previously been shown to support endothelial cell growth in vitro. A bespoke electrospray deposition process provided control over the coating thickness, surface roughness, drug load, and release kinetics. The resultant optimised coating combines rapid release of an anti-proliferative agent from a bioactive polymer coating that promotes re-endothelialisation, thereby offering potential protection against in-stent restenosis and thrombosis. This novel, dual-action coating therefore has significant therapeutic potential, with the enhanced control of drug load and release kinetics offered by electrospray deposition also opening up opportunities for more personalised treatment approaches. Further development and evaluation of these technologies in vitro and in vivo is therefore warranted.

Soft-sheath, stiff-core microfiber hydrogel for coating vascular implants

Vascular implants remain clinically challenged due to often-occurring thrombosis and stenosis. Critical to addressing these complications is the design of implant material surfaces to inhibit the activities of platelets, smooth muscle cells (SMCs) and inflammatory cells. Recent mechanobiology studies accentuate the significance of material elasticity to cells and tissues. We thus developed and characterized an implant coating composed of hybrid, viscoelastic microfibers with coaxial core-sheath nanostructure. The coating over metallic stent material was formed by first depositing coaxially-electrospun fibers of poly(L-lactic acid) core and polyethylene glycol dimethacrylate sheath, and then polymerizing fibers with various UV times. Material characterizations were performed to evaluate the coating structure, mechanical property and biocompatibility. Results showed that coaxial microfibers exhibited arterial-like mechanics. The soft surface, high water content and swelling ratio of the coaxial fibers resemble hydrogels, while they are mechanically strong with an elastic modulus of 172-729 kPa. The coating strength and surface elasticity were tunable with the photopolymerization time. Further, the elastic fibers, as conformal coating on stent metal, strongly reduced SMC overgrowth and discouraged platelet adhesion and activation, compared to bare metals. Importantly, after 7-day subcutaneous implantation, coaxial fiber-coated implants showed more favorable in vivo responses with reduced tissue encapsulation, compared to bare stent metals or those coated with a two-layered fiber mixture composed of fibers from individual polymers. The excellent biocompatibility aroused from nanostructural interfaces of hybrid fibers offering hydrated, soft, nonfouling microenvironments. Such integrated fiber system may allow creation of advanced vascular implants that possess physico-mechanical properties of native arteries.

Multifunctionalized polyethersulfone membranes with networked submicrogels to improve antifouling property, antibacterial adhesion and blood compatibility

Intensive efforts have been employed in modifying biomedical membranes. Among them, blending is recognized as a simple method. However, the conventional blending materials commonly lead to an insufficient modification, which is mainly caused by the poor miscibility between the blending materials and the matrixes, the elution of the hydrophilic materials from the matrixes during the use and storage, and the insufficient surface enrichment of the blending materials. Aiming to solve the abovementioned disadvantages, we developed novel polyethersulfone/poly(acrylic acid-co-N-vinyl-2-pyrrolidone) networked submicrogels (PES/P(AA-VP) NSs), which were blended with PES to enhance the antifouling properties, antibacterial adhesion and haemocompatible properties of PES membranes. As results, the PES/P(AA-VP) NSs showed good miscibility with the PES matrix, and hydrophilic submicrogels would enrich onto the membrane surface during the phase inversion process due to the surface segregation. The entanglement between the PES matrix and the networked submicrogels would effectively limit the elution of the submicrogels. In conclusion, the modified PES membranes prepared by blending with the PES/P(AA-VP) NSs might draw great attention for the application in haemodialysis fields.

Surface modification of stainless steel for biomedical applications: Revisiting a century-old material

Stainless steel (SS) has been widely used as a material for fabricating cardiovascular stents/valves, orthopedic prosthesis, and other devices and implants used in biomedicine due to its malleability and resistance to corrosion and fatigue. Despite its good mechanical properties, SS (as other metals) lacks biofunctionality. To be successfully used as a biomaterial, SS must be made resistant to the biological environment by increasing its anti-fouling properties, preventing biofilm formation (passive surface modification), and imparting functionality for eluting a specific drug or capturing selected cells (active surface modification); these features depend on the final application. Various physico-chemical techniques, including plasma vapor deposition, electrochemical treatment, and attachment of different linkers that add functional groups, are used to obtain SS with increased corrosion resistance, improved osseointegration capabilities, added hemocompatibility, and enhanced antibacterial properties. Existing literature on this topic is extensive and has not been covered in an integrated way in previous reviews. This review aims to fill this gap, by surveying the literature on SS surface modification methods, as well as modification routes tailored for specific biomedical applications.

STATEMENT OF SIGNIFICANCE

Stainless steel (SS) is widely used in many biomedical applications including bone implants and cardiovascular stents due to its good mechanical properties, biocompatibility and low price. Surface modification allows improving its characteristics without compromising its important bulk properties. SS with improved blood compatibility (blood contacting implants), enhanced ability to resist bacterial infection (long-term devices), better integration with a tissue (bone implants) are examples of successful SS surface modifications. Existing literature on this topic is extensive and has not been covered in an integrated way in previous reviews. This review paper aims to fill this gap, by surveying the literature on SS surface modification methods, as well as to provide guidance for selecting appropriate modification routes tailored for specific biomedical applications.

The Surface Modification Methods for Constructing Polymer-Coated Stents

Implanting a metal stent plays a key role in treating cardiovascular diseases. However, the high corrosion rate of metal-based devices severely limits their practical applications. Therefore, how to control the corrosion rate is vital to take full advantages of metal-based materials in the treatment of cardiovascular diseases. This review details various methods to design and construct polymer-coated stents. The techniques are described and discussed including plasma deposition, electrospinning, dip coating, layer-by-layer self-assembly, and direct-write inkjet. Key point is provided to highlight current methods and recent advances in hindering corrosion rate and improving biocompatibility of stents, which greatly drives the rising of some promising techniques involved in the ongoing challenges and potential new trends of polymer-coated stents.

Surface modification of endovascular stents with rosuvastatin and heparin-loaded biodegradable nanofibers by electrospinning

This study describes the development of drug-loaded nanofibrous scaffolds as a nanocoating for endovascular stents for the local and sustained delivery of rosuvastatin (Ros) and heparin (Hep) to injured artery walls after endovascular procedures via the electrospinning process.

PURPOSE

The proposed hybrid covered stents can promote re-endothelialization; improve endothelial function; reduce inflammatory reaction; inhibit neointimal hyperplasia of the injured artery wall, due to well-known pleiotropic actions of Ros; and prevent adverse events such as in-stent restenosis (ISR) and stent thrombosis (ST), through the antithrombotic action of Hep.

METHODS

Biodegradable nanofibers were prepared by dissolving cellulose acetate (AC) and Ros in N,N-dimethylacetamide (DMAc) and acetone-based solvents. The polymeric solution was electrospun (e-spun) into drug-loaded AC nanofibers onto three different commercially available stents (Co-Cr stent, Ni-Ti stent, and stainless steel stent), resulting in nonwoven matrices of submicron-sized fibers. Accordingly, Hep solution was further used for fibrous coating onto the engineered Ros-loaded stent. The functional encapsulation of Ros and Hep drugs into polymeric scaffolds further underwent physicochemical analysis. Morphological characterization took place via scanning electron microscopy (SEM) and atomic force microscopy (AFM) analyses, while scaffolds' wettability properties were obtained by contact angle (CA) measurements.

RESULTS

The morphology of the drug-loaded AC nanofibers was smooth, with an average diameter of 200-800 nm, and after CA measurement, we concluded to the superhydrophobic nature of the engineered scaffolds. In vitro release rates of the pharmaceutical drugs were determined using a high-performance liquid chromatography assay, which showed that after the initial burst, drug release was controlled slowly by the degradation of the polymeric materials.

CONCLUSION

These results imply that AC nanofibers encapsulated with Ros and Hep drugs have great potential in the development of endovascular grafts with anti-thrombogenic properties that can accelerate the re-endothelialization, reduce the neointimal hyperplasia and inflammatory reaction, and improve the endothelial function.

Initial contact guidance during cell spreading is contractility-independent

A wide variety of cell types exhibit substrate topography-based behavior, also known as contact guidance. However, the precise cellular mechanisms underlying this process are still unknown. In this study, we investigated contact guidance by studying the reaction of human endothelial cells (ECs) to well-defined microgroove topographies, both during and after initial cell spreading. As the cytoskeleton plays a major role in cellular adaptation to topographical features, two methods were used to perturb cytoskeletal structures. Inhibition of actomyosin contractility with the chemical inhibitor blebbistatatin demonstrated that initial contact guidance events are independent of traction force generation. However, cell alignment to the grooved substrate was altered at later time points, suggesting an initial 'passive' phase of contact guidance, followed by a contractility-dependent 'active' phase that relies on mechanosensitive feedback. The actin cytoskeleton was also perturbed in an indirect manner by culturing cells upside down, resulting in decreased levels of contact guidance and suggesting that a possible loss of contact between the actin cytoskeleton and the substrate could lead to cytoskeleton impairment. The process of contact guidance at the microscale was found to be primarily lamellipodia driven, as no bias in filopodia extension was observed on micron-scale grooves.

Sulfonated chitosan and dopamine based coatings for metallic implants in contact with blood

Thrombosis and calcification constitute the main clinical problems when blood-interacting devices are implanted in the body. Coatings with thin polymer layers represent an acknowledged strategy to modulate interactions between the material surface and the blood environment. To ensure the implant success, at short-term the coating should limit platelets adhesion and delay the clot formation, and at long-term it should delay the calcification process. Sulfonated chitosan, if compared to native chitosan, shows the unique ability to reduce proteins adsorption, decrease thrombogenic properties and limit calcification. In this work, stainless steel surfaces, commonly used for cardiovascular applications, were coated with sulfonated chitosan, by using dopamine and PEG as anchors, and the effect of these grafted surfaces on platelet adhesion, clot formation as well as on calcification were investigated. Surface characterization techniques evidenced that the coating formation was successful, and the sulfonated chitosan grafted sample exhibited a higher roughness and hydrophilicity, if compared to native chitosan one. Moreover, sulfonated surface limited platelet activation and the process of clot formation, thus confirming its high biological performances in blood. Calcium deposits were also lower on the sulfonated chitosan sample compared to the chitosan one, thus showing that calcification was minimal in presence of sulfonate groups. In conclusion, this sulfonated-modified surface has potential to be as blood-interacting material.

Tissue-engineered trachea: A review

Tracheal replacement is performed after resection of a portion of the trachea that was impossible to reconnect via direct anastomosis. A tissue-engineered trachea is one of the available options that offer many advantages compared to other types of graft. Fabrication of a functional tissue-engineered trachea for grafting is very challenging, as it is a complex organ with important components, including cartilage, epithelium and vasculature. A number of studies have been reported on the preparation of a graftable trachea. A laterally rigid but longitudinally flexible hollow cylindrical scaffold which supports cartilage and epithelial tissue formation is the key element. The scaffold can be prepared via decellularization of an allograft or fabricated using biodegradable or non-biodegradable biomaterials. Commonly, the scaffold is seeded with chondrocytes and epithelial cells at the outer and luminal surfaces, respectively, to hasten tissue formation and improve functionality. To date, several clinical trials of tracheal replacement with tissue-engineered trachea have been performed. This article reviews the formation of cartilage tissue, epithelium and neovascularization of tissue-engineered trachea, together with the obstacles, possible solutions and future. Furthermore, the role of the bioreactor for in vitro tracheal graft formation and recently reported clinical applications of tracheal graft were also discussed. Generally, although encouraging results have been achieved, however, some obstacles remain to be resolved before the tissue-engineered trachea can be widely used in clinical settings.

Polymeric nanobiocomposites for biomedical applications

Polymeric nanobiocomposites have recently become one of the most essential sought after materials for biomedical applications ranging from implants to the creation of gels. Their unique mechanical and biological properties provide them the ability to pass through the highly guarded defense mechanism without undergoing noticeable degradation and initiation of immune responses, which in turn makes them advantageous over the other alternatives. Aligned with the advances in tissue engineering, it is also possible to design three-dimensional extracellular matrix using these polymeric nanobiocomposites that could closely mimic the human tissues. In fact, unique polymer chemistry coupled with nanoparticles could create unique microenvironment that promotes cell growth and differentiation. In addition, the nanobiocomposites can also be devised to carry drugs efficiently to the target site without exhibiting any cytotoxicity as well as to eradicate surgical infections. In this article, an effort has been made to thoroughly review a number of different types/classes of polymeric nanocomposites currently used in biomedical fields. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1241-1259, 2017.

The metamorphosis of vascular stents: passive structures to smart devices

The role of nanotechnology enabled techniques in the evolution of vascular stents.

Core-shell PVA/gelatin electrospun nanofibers promote human umbilical vein endothelial cell and smooth muscle cell proliferation and migration

Cardiovascular disease is the leading cause of death in the world. In this study, coaxial electrospinning is employed to fabricate fibers in a core-shell structure with polyvinyl alcohol (PVA) in the core and gelatin in the shell for evaluation as a potential vascular tissue engineering construct. PVA, a synthetic polymer, provides mechanical strength to the biocompatible and weak gelatin sheath. The HUVEC (human umbilical vein endothelial cells) and rSMC (rat smooth muscle cells) demonstrated a flattened morphology with multiple attachment sites on the gelatin and coaxial scaffolds, with an increase in cell spreading seen as mechanical stiffness of the scaffold increased. Additionally, HUVEC had an increase in migration on the coaxial scaffolds, which was attributed to the increase in stiffness; however, this increase in migration was not seen with the rSMC, which had the highest outward migration on the flat surfaces (tissue culture polystyrene and gelatin film). Overall, these scaffolds are appealing substrates for vascular tissue engineering applications.

STATEMENT OF SIGNIFICANCE

The worldwide burden of cardiovascular disease presents an ongoing need and opportunity for creating a variety of vascular prostheses. Fabrication of novel scaffolds and constructs for these are needed, providing strength and biological properties facilitating endothelial (EC) and smooth muscle (SMC) cell attachment, migration, and integration. Using electrospinning we formed 3D core:shell nanofibers and examined their effectiveness as substrates for EC and SMC attachment and growth, compared to a 2D (flat) substrate. We found that ECs attached and grew best on 3D core:shell fibers, whereas SMCs favored 2D gelatin surfaces. Interestingly, we found that EC attachment, migration and growth correlated and improved with increasing fiber stiffness. These materials and insights may foster novel vascular prostheses development.

Next generation covered stents made from nanocomposite materials: A complete assessment of uniformity, integrity and biomechanical properties

Covered stents are stents wrapped with a thin polymeric membrane, and are typically used to treat vessel aneurysms and seal perforated arteries. Current covered stents suffer from restenosis due to limitations in material and fabrication methods which leaves metallic struts directly exposed to blood. We have developed a biocompatible and haemocompatible nanocomposite polymer, polyhedral oligomeric silsesquioxane poly(carbonate-urea) urethane (POSS-PCU). We devised a novel combination of ultrasonic spray atomisation system and dip-coating process to produce small calibre covered stents with metal struts fully embedded within the membrane, which also yields greater coating uniformity. Stent-polymer bonding was enhanced via silanisation and coating of reactive pre-polymer. Platelet studies supported the non-thrombogenicity of POSS-PCU. Biomechanical performances including diametrical compliance, bending strength, radial strength and recoil were evaluated and optimised. This proof-of-principle manufacturing technique could lead to the development of next-generation small calibre adult and paediatric covered stents. These stents are currently undergoing preclinical trial. From the Clinical Editor: The use of stents to treat vascular diseases is now the standard of care in the clinical setting. Nonetheless, a major problem of the current stents is the risk of restenosis and thrombosis. The authors developed a nanocomposite material using polyhedral oligomeric silsesquioxane and poly(carbonate-urea) urethane (POSS-PCU) and incorporated into metallic stents. Preliminary data have already shown promising results. It is envisaged that this would further lead to better stent technology in the future.

Tangible nanocomposites with diverse properties for heart valve application

Cardiovascular disease claims millions of lives every year throughout the world. Biomaterials are used widely for the treatment of this fatal disease. With the advent of nanotechnology, the use of nanocomposites has become almost inevitable in the field of biomaterials. The versatile properties of nanocomposites, such as improved durability and biocompatibility, make them an ideal choice for various biomedical applications. Among the various nanocomposites, polyhedral oligomeric silsesquioxane-poly(carbonate-urea)urethane, bacterial cellulose with polyvinyl alcohol, carbon nanotubes, graphene oxide and nano-hydroxyapatite nanocomposites have gained popularity as putative choices for biomaterials in cardiovascular applications owing to their superior properties. In this review, various studies performed utilizing these nanocomposites for improving the mechanical strength, anti-calcification potential and hemocompatibility of heart valves are reviewed and summarized. The primary motive of this work is to shed light on the emerging nanocomposites for heart valve applications. Furthermore, we aim to promote the prospects of these nanocomposites in the campaign against cardiovascular diseases.

Spatio-Temporal Control of LbL Films for Biomedical Applications: From 2D to 3D

Introduced in the '90s by Prof. Moehwald, Lvov, and Decher, the layer-by-layer (LbL) assembly of polyelectrolytes has become a popular technique to engineer various types of objects such as films, capsules and free standing membranes, with an unprecedented control at the nanometer and micrometer scales. The LbL technique allows to engineer biofunctional surface coatings, which may be dedicated to biomedical applications in vivo but also to fundamental studies and diagnosis in vitro. Initially mostly developed as 2D coatings and hollow capsules, the range of complex objects created by the LbL technique has greatly expanded in the past 10 years. In this Review, the aim is to highlight the recent progress in the field of LbL films for biomedical applications and to discuss the various ways to spatially and temporally control the biochemical and mechanical properties of multilayers. In particular, three major developments of LbL films are discussed: 1) the new methods and templates to engineer LbL films and control cellular processes from adhesion to differentiation, 2) the major ways to achieve temporal control by chemical, biological and physical triggers and, 3) the combinations of LbL technique, cells and scaffolds for repairing 3D tissues, including cardio-vascular devices, bone implants and neuro-prosthetic devices.

Hemocompatibility of Poly(vinyl alcohol)-Gelatin Core-Shell Electrospun Nanofibers: A Scaffold for Modulating Platelet Deposition and Activation

In this study, we evaluate coaxial electrospun nanofibers with gelatin in the shell and poly(vinyl alcohol) (PVA) in the core as a potential vascular material by determining fiber surface roughness, as well as human platelet deposition and activation under varying conditions. PVA scaffolds had the highest surface roughness (Ra=65.5±6.8 nm) but the lowest platelet deposition (34.2±5.8 platelets) in comparison to gelatin nanofibers (Ra=36.8±3.0 nm and 168.9±29.8 platelets) and coaxial nanofibers (1 Gel:1 PVA coaxial, Ra=24.0±1.5 nm and 150.2±17.4 platelets. 3 Gel:1 PVA coaxial, Ra=37.1±2.8 nm and 167.8±15.4 platelets). Therefore, the chemical structure of the gelatin nanofibers dominated surface roughness in platelet deposition. Due to their increased stiffness, the coaxial nanofibers had the highest platelet activation rate, rate of thrombin formation, in comparison to gelatin and PVA fibers. Our studies indicate that mechanical stiffness is a dominating factor for platelet deposition and activation, followed by biochemical signals, and lastly surface roughness. Overall, these coaxial nanofibers are an appealing material for vascular applications by supporting cellular growth while minimizing platelet deposition and activation.

Surface modification and endothelialization of biomaterials as potential scaffolds for vascular tissue engineering applications

This review highlights the recent developments of surface modification and endothelialization of biomaterials in vascular tissue engineering applications.

Biomimetic modified clinical-grade POSS-PCU nanocomposite polymer for bypass graft applications: a preliminary assessment of endothelial cell adhesion and haemocompatibility

BACKGROUND

To date, there are no small internal diameter (<5mm) vascular grafts that are FDA approved for clinical use due to high failure rates from thrombosis and unwanted cell proliferation. The ideal conditions to enhance bioengineered grafts would be the blood contacting lumen of the bypass graft fully covered by endothelial cells (ECs). As a strategy towards this aim, we hypothesized that by immobilising biomolecules on the surface of the polyhedral oligomeric silsesquioxane-poly(carbonate-urea)urethane (POSS-PCU) nanocomposite polymers, which contain binding sites and ligands for cell surface receptors similar to extracellular matrix (ECM) will positively influence the attachment and proliferation of ECs. Since, the surface of POSS-PCU is inert and not directly suitable for immobilisation of biomolecules, plasma graft polymerisation is a suitable method to modify the surface properties ready for immobilisation and biofunctionalisation.

METHODS

POSS-PCU was activated by plasma treatment in air/O2 to from hydroperoxides (-OH, -OOH), and then carboxylated via plasma polymerisation of a 30% acrylic acid solution (Poly-AA) using a two-step plasma treatment (TSPT) process. Collagen type I, a major component of ECM, was covalently immobilised to mimic the ECM structures to ECs (5mg/ml) using a two-step chemical reaction using EDC chemistry. Successful immobilisation of poly-AA and collagen on to the nanocomposites was confirmed using Toluidine Blue staining and the Bradford assay. Un-treated POSS-PCU served as a simple control. The impact of collagen grafting on the physical, mechanical and biological properties of POSS-PCU was evaluated via contact angle (θ) measurements, scanning electron microscopy (SEM), atomic force microscopy (AFM), dynamic mechanical thermal analysis (DMTA), ECs adhesion and proliferation followed by platelet adhesion and haemolysis ratio (HR) tests.

RESULTS

Poly-AA content on each of the plasma treated nanocomposite films increased on Low, Med and High samples due to more carboxylic acid (-COOH) groups at the surface forming amide (-NH2) bonds. The amount of -COOH groups on each of the Low, Med and High nanocomposites correlated with Poly-AA grafting density at 14.7±0.9, 18.9±0.9, and 34.2±2.4 μg/cm(2). Immobilisation of collagen type I on to nanocomposite surface was also found to increase significantly on the Low, Med and High samples from 22±4, 150±15, and 219±17 μg/cm(2), respectively. The level of ECs and their adhesion efficiency were improved with increasing amounts of grafted collagen I. The maximum adhesion of ECs was found on the highest collagen type I coated nanocomposites. Platelet adhesion and activation also increased with increasing collagen density. The obtained HR values for all of the treated samples were well within the acceptable standards for biomaterials (<5% HR).

CONCLUSION

Poly-AA-g-POSS-PCU surfaces offer binding sites for the covalent bonding of collagen type I and other biomolecules such as fibronectin by exposure of RGD cell binding domains and growth factors using EDC cross-linking chemistry. Collagen type I modification can yield accelerated EC growth and enhance the endothelialisation of POSS-PCU nanocomposites, and the amount of immobilised collagen can control the level of platelet adhesion on functionalized POSS-PCU via TSPT and poly acrylic acid (poly-AA) treatment. Such surface modification procedures of polymeric surfaces can improve the patency rate of POSS-PCU nanocomposites as vascular bypass grafts in the preparation of a range of medical devices ready for pre-clinical and in vivo evaluation.

Carotid artery stenting: current and emerging options

Carotid artery stenting technologies are rapidly evolving. Options for endovascular surgeons and interventionists who treat occlusive carotid disease continue to expand. We here present an update and overview of carotid stenting devices. Evidence supporting carotid stenting includes randomized controlled trials that compare endovascular stenting to open surgical endarterectomy. Carotid technologies addressed include the carotid stents themselves as well as adjunct neuroprotective devices. Aspects of stent technology include bare-metal versus covered stents, stent tapering, and free-cell area. Drug-eluting and cutting balloon indications are described. Embolization protection options and new direct carotid access strategies are reviewed. Adjunct technologies, such as intravascular ultrasound imaging and risk stratification algorithms, are discussed. Bare-metal and covered stents provide unique advantages and disadvantages. Stent tapering may allow for a more fitted contour to the caliber decrement between the common carotid and internal carotid arteries but also introduces new technical challenges. Studies regarding free-cell area are conflicting with respect to benefits and associated risk; clinical relevance of associated adverse effects associated with either type is unclear. Embolization protection strategies include distal filter protection and flow reversal. Though flow reversal was initially met with some skepticism, it has gained wider acceptance and may provide the advantage of not crossing the carotid lesion before protection is established. New direct carotid access techniques address difficult anatomy and incorporate sophisticated flow-reversal embolization protection techniques. Carotid stenting is a new and exciting field with rapidly advancing technologies. Embolization protection, low-risk deployment, and lesion assessment and stratification are active areas of research. Ample room remains for further innovations and developments.

Deposition of organic−inorganic hybrid coatings over 316L surgical stainless steel and evaluation on vascular cells

Surface coating of metallic materials using the sol-gel technique is a suitable approach to obtain hybrid materials with improved properties for biomedical applications. In this study, an AISI 316L stainless steel surface was coated with ormosils prepared from tetraethylsiloxane and 3-glycidoxypropyltrimethoxysilane or polydimethylsiloxane. The characterization of structural and surface properties was performed by several techniques. Surface microstructure, morphology, and energy are dependent on organosilane type and content. Chemical stability of coatings was investigated by static immersion tests in phosphate buffer solution at 37 °C, and silicon leaching after 21 days was found to be in the range of ∼200−300 μg L−1. Mechanical adhesion was found to be within 1.0 and 3.7 N cm−1. The interaction of the samples and materials in the cardiovascular environment was investigated through cellular behavior. Biological assays were performed with slides to avoid any cytotoxic effects on human endothelial cells (HUVEC) and rabbit arterial smooth muscle cells (RASM). No significant alterations were observed after 24 h in the viability of RASM and HUVEC cells exposed to different coatings. No increase of HUVEC or RASM migration was observed after 24 h as evaluated by transwell migration assay. The hybrid materials showed suitable properties for potential application as biomaterials in cardiovascular environment as well as for incorporation of bioactive species with the aim to prepare drug-eluting stents.