Bio-Adaption between Magnesium Alloy Stent and the Blood Vessel: A Review

Mitigation of arteriosclerosis through transcriptional regulation of ferroptosis and lipid metabolism by magnesium

Metallic cardiovascular stents are crucial for preventing atherosclerosis-induced infarction by offering mechanical support. However, the effects of metal ions released from these stents on atherosclerosis remain ambiguous. This study evaluates the potential impact posed by the degradation products of magnesium-based stents, with a focus on ferroptosis, a key mechanism driving atherosclerosis. Remarkably, our results demonstrate that Mg effectively inhibits ferroptosis in human umbilical vein endothelial cells and in murine, rat and rabbit models. Our studies reveal that magnesium ions impede the dephosphorylation of ERK proteins, thereby enhancing the expression of SLC7A11 and GCL proteins via activation of the MAPK pathway mechanistically. Additionally, magnesium ions downregulate ACSL4 protein expression, leading to decreased levels of acyl-CoA and ether-phospholipids. Eventually, multiple animal experiments indicate that biodegradable Mg stents can inhibit ferroptosis and decelerate the progression of arteriosclerosis, highlighting the therapeutic potential of Mg stents in treating arteriosclerosis.

Corrosion resistance and biocompatibility of carbon ion implanted AZ31B magnesium alloy

The poor corrosion resistance of magnesium limits its clinical applications. Accordingly, in the present study, carbon ions were incorporated into a AZ31b magnesium alloy surface via carbon plasma immersion ion-implantation to improve its corrosion resistance and biocompatibility. The surface morphology and properties of the modified alloy were evaluated by field-emission scanning electron microscopy, water contact angle measurement, Raman scattering, X-ray photoelectron spectroscopy, and energy dispersive X-ray spectroscopy. Furthermore, compositional depth profiles were obtained by glow discharge optical emission spectroscopy, revealing a Gaussian-like distribution of carbon concentration. Electrochemical and hydrogen-evolution analysis demonstrated the successfully improved corrosion resistance of the AZ31b Mg alloy, while its biocompatibility was demonstrated by MTT and cell-adherence assays.

Evolution of Atomic-Level Interfacial Fracture Mechanics in Magnesium-Zinc Compounds Used for Bioresorbable Vascular Stents

Bioresorbable magnesium-metal vascular stents are gaining popularity due to their biodegradable nature and good biological and mechanical properties. They are also suitable candidate materials for biodegradable stents. Due to the rapid degradation rate of Mg metal vascular scaffolds, a Mg/Zn bilayer composite was formed by a number of means, such as magnetron sputtering and physical vapor deposition, thus delaying the degradation time of the Mg metal vascular scaffolds while providing good radial support for the stenotic vessels. However, the interlaminar compounds at the metal interface have an essential impact on the mechanical properties of the bi-material interface, especially the cracking and delamination of the Mg matrix Zn coating vascular stent in the radially expanded process layer. Intermetallic compounds (IMCs) are commonly found in dual-layer composites, such as Mg/Zn composites and multi-layer structures. They are frequently overlooked in simulations aiming to predict mechanical properties. This paper analyses the interfacial failure processes and evolutionary mechanisms of interfacial fracture mechanics of a Mg/Zn interface with an intermetallic compound layer between coated Zn and Mg matrix metallic vascular stents. The simulation results show that the fracture mode in the Mg/Zn interface with an intermetallic compound involves typical ductile fracture under static tensile conditions. The dislocation line defects mainly occur on the side of the Mg, which induces the Mg/Zn interfacial crack to expand along the interface into the pure Mg. The stress intensity factor and the critical strain energy release rate decrease as the intermetallic compound layer's thickness gradually increases, indicating that the intensity of stress and the force of the crack extending and expanding along the crack tip are weakened. The presence of intermetallic compounds at the interface can significantly strengthen the mechanical properties of the material interface and alleviate the crack propagation between the interfaces.

Long-term efficacy, safety and biocompatibility of a novel sirolimus eluting iron bioresorbable scaffold in a porcine model

Iron is considered as an attractive alternative material for bioresorbable scaffolds (BRS). The sirolimus eluting iron bioresorbable scaffold (IBS), developed by Biotyx Medical (Shenzhen, China), is the only iron-based BRS with an ultrathin-wall design. The study aims to investigate the long-term efficacy, safety, biocompatibility, and lumen changes during the biodegradation process of the IBS in a porcine model. A total of 90 IBSs and 70 cobalt-chromium everolimus eluting stents (EES) were randomly implanted into nonatherosclerotic coronary artery of healthy mini swine. The multimodality assessments including coronary angiography, optical coherence tomography, micro-computed tomography, magnetic resonance imaging, real-time polymerase chain reaction (PCR), and histopathological evaluations, were performed at different time points. There was no statistical difference in area stenosis between IBS group and EES group at 6 months, 1year, 2 years and 5 years. Although the scaffolded vessels narrowed at 9 months, expansive remodeling with increased mean lumen area was found at 3 and 5 years. The IBS struts remained intact at 6 months, and the corrosion was detectable at 9 months. At 5 years, the iron struts were completely degraded and absorbed in situ, without in-scaffold restenosis or thrombosis, lumen collapse, aneurysm formation, and chronic inflammation. No local or systemic toxicity and abnormal histopathologic manifestation were found in all experiments. Results from real-time PCR indicated that no sign of iron overload was reported in scaffolded segments. Therefore, the IBS shows comparable efficacy, safety, and biocompatibility with EES, and late lumen enlargement is considered as a unique feature in the IBS-implanted vessels.

Exploring the biodegradability of candidate metallic intravascular stent materials using X-ray microfocus computed tomography: An in vitro study

In vitro testing for evaluating degradation mode and rate of candidate biodegradable metals to be used as intravascular stents is crucial before going to in vivo animal models. In this study, we show that X-ray microfocus computed tomography (microCT) presents a key added value to visualize degradation mode and to evaluate degradation rate and material surface properties in 3D and at high resolution of large regions of interest. The in vitro degradation behavior of three candidate biodegradable stent materials was evaluated: pure iron (Fe), pure zinc (Zn), and a quinary Zn alloy (ZnAgCuMnZr). These metals were compared to a reference biostable cobaltchromium (CoCr) alloy. To compare the degradation mode and degradation rate evaluated with microCT, scanning electron microscopy (SEM) and inductively-coupled plasma (ICP) were included. We confirmed that Fe degrades very slowly but with desirable uniform surface corrosion. Zn degrades faster but exhibits localized deep pitting corrosion. The Zn alloy degrades at a similar rate as the pure Zn, but more homogeneously. However, the formation of deep internal dendrites was observed. Our study provides a detailed microCT-based comparison of essential surface and corrosion properties, with a structural characterization of the corrosion behavior, of different candidate stent materials in 3D in a non-destructive way.

Bioresorbable Scaffolds for Below-the-Knee Arterial Disease: A Literature Review of New Developments

This review aimed to explore the therapeutic effect of bioabsorbable stents in the inferior genicular artery, from the emergence of absorbable bare metal stents to the latest technology in polymer and anti-proliferative eluting drugs mixed with coated bioresorbable vascular stents (BVSs). Currently, there are conflicting data regarding the safety and effectiveness of BVSs in infrapopliteal artery interventions, especially compared to the current generation of drug-eluting stents (DESs). This review will cover the existing data on BVSs in reconstructing the infrapopliteal arterial blood flow and active clinical trials for future iterations of BVSs. In terms of primary patency rate and target lesion revascularization rate, the available research on the effectiveness of BVSs in reconstructing the infrapopliteal arterial blood flow suggests that a BVS is compatible with current DESs within 3-12 months; long-term data have not yet been reported. The ABSORB BVS is the most studied BVS in cardiovascular disease (CAD). Initially, the ABSORB BVS showed promising results. Managing intricate regions in peripheral artery disorders, such as branching or lengthy lesions, continues to be a formidable undertaking. In contrast to the advanced narrowing of arteries seen in standard permanent stent procedures, bioabsorbable stents have the potential to promote the expansion and beneficial merging of blood channels in the latter stages. Furthermore, incorporating stents and re-establishing the endothelial function can diminish the probability of restenosis or thrombosis. Nevertheless, the extent to which bioabsorbable stents may simultaneously preserve arterial patency and guarantee their structural integrity remains uncertain. The powerful and intricate mechanical stresses exerted by the blood in the superficial femoral artery and popliteal artery can cause negative consequences on any implant inserted into the vessel, regardless of its composition, even metal. Furthermore, incorporating stents is advantageous for treating persistent occlusive lesions since it does not impact later treatments, including corrective bypass operations. Evidence is scarce about the use of bioabsorbable stents in treating infrapopliteal lesions. Utilizing bioabsorbable stents in minor infrapopliteal lesions can successfully maintain the patency of the blood vessel lumen, whereas balloon angioplasty cannot offer this benefit. The primary focus of testing these materials is determining whether bioabsorbable scaffolds can provide adequate radial force in highly calcified elongated lesions. Indeed, using "-limus" medication elution technology in conjunction with bioabsorbable stents has previously offered clinical benefits in treating the popliteal artery, as evidenced by limited trials.BVSs for peripheral arterial disease (PAD) show promise and have the potential to offer a less inflammatory and more vessel-friendly option compared to permanent metallic stents. However, current evidence does not yet allow for a universal recommendation for their use. Thus, ongoing, and future studies, such as those examining the newer generation of bioresorbable scaffolds (BRSs) with improved mechanical properties and resorption profiles, will be crucial in defining the role of BRSs in managing PAD.

Bone Regeneration Induced by Patient-Adapted Mg Alloy-Based Scaffolds for Bone Defects: Present and Future Perspectives

Treatment of bone defects resulting after tumor surgeries, accidents, or non-unions is an actual problem linked to morbidity and the necessity of a second surgery and often requires a critical healthcare cost. Although the surgical technique has changed in a modern way, the treatment outcome is still influenced by patient age, localization of the bone defect, associated comorbidities, the surgeon approach, and systemic disorders. Three-dimensional magnesium-based scaffolds are considered an important step because they can have precise bone defect geometry, high porosity grade, anatomical pore shape, and mechanical properties close to the human bone. In addition, magnesium has been proven in in vitro and in vivo studies to influence bone regeneration and new blood vessel formation positively. In this review paper, we describe the magnesium alloy's effect on bone regenerative processes, starting with a short description of magnesium's role in the bone healing process, host immune response modulation, and finishing with the primary biological mechanism of magnesium ions in angiogenesis and osteogenesis by presenting a detailed analysis based on a literature review. A strategy that must be followed when a patient-adapted scaffold dedicated to bone tissue engineering is proposed and the main fabrication technologies are combined, in some cases with artificial intelligence for Mg alloy scaffolds, are presented with examples. We emphasized the microstructure, mechanical properties, corrosion behavior, and biocompatibility of each study and made a basis for the researchers who want to start to apply the regenerative potential of magnesium-based scaffolds in clinical practice. Challenges, future directions, and special potential clinical applications such as osteosarcoma and persistent infection treatment are present at the end of our review paper.

Long-Term Temporospatial Complementary Relationship between Degradation and Bone Regeneration of Mg-Al Alloy

The utilization of guided tissue regeneration membranes is a significant approach for enhancing bone tissue growth in areas with bone defects. Biodegradable magnesium alloys are increasingly being used as guided tissue regeneration membranes due to their outstanding osteogenic properties. However, the degradation rates of magnesium alloy bone implants documented in the literature tend to be rapid. Moreover, many studies focus only on the initial 3-month period post-implantation, limiting their applicability and impeding clinical adoption. Furthermore, scant attention has been given to the interplay between the degradation of magnesium alloy implants and the adjacent tissues. To address these gaps, this study employs a well-studied magnesium-aluminum (Mg-Al) alloy membrane with a slow degradation rate. This membrane is implanted into rat skull bone defects and monitored over an extended period of up to 48 weeks. Observations are conducted at various intervals (2, 4, 8, 12, 24, and 48 weeks) following the implantation. Assessment of degradation behavior and tissue regeneration response is carried out using histological sections, micro-CT scans, and scanning electron microscopy (SEM). The findings reveal that the magnesium alloy membranes demonstrate remarkable biocompatibility and osteogenic capability over the entire observation duration. Specifically, the Mg-Al alloy membranes sustain their structural integrity for 8 weeks. Notably, their osteogenic ability is further enhanced as a corrosion product layer forms during the later stages of implantation. Additionally, our in vitro experiments employing extracts from the magnesium alloy display a significant osteogenic effect, accompanied by a notable increase in the expression of osteogenic-related genes. Collectively, these results strongly indicate the substantial potential of Mg-Al alloy membranes in the context of guided tissue regeneration.

GelMA-based bioactive hydrogel scaffolds with multiple bone defect repair functions: therapeutic strategies and recent advances

Currently, the clinical treatment of critical bone defects attributed to various causes remains a great challenge, and repairing these defects with synthetic bone substitutes is the most common strategy. In general, tissue engineering materials that mimic the structural, mechanical and biological properties of natural bone have been extensively applied to fill bone defects and promote in situ bone regeneration. Hydrogels with extracellular matrix (ECM)-like properties are common tissue engineering materials, among which methacrylate-based gelatin (GelMA) hydrogels are widely used because of their tunable mechanical properties, excellent photocrosslinking capability and good biocompatibility. Owing to their lack of osteogenic activity, however, GelMA hydrogels are combined with other types of materials with osteogenic activities to improve the osteogenic capability of the current composites. There are three main aspects to consider when enhancing the bone regenerative performance of composite materials: osteoconductivity, vascularization and osteoinduction. Bioceramics, bioglass, biomimetic scaffolds, inorganic ions, bionic periosteum, growth factors and two-dimensional (2D) nanomaterials have been applied in various combinations to achieve enhanced osteogenic and bone regeneration activities. Three-dimensional (3D)-bioprinted scaffolds are a popular research topic in bone tissue engineering (BTE), and printed and customized scaffolds are suitable for restoring large irregular bone defects due to their shape and structural tunability, enhanced mechanical properties, and good biocompatibility. Herein, the recent progress in research on GelMA-based composite hydrogel scaffolds as multifunctional platforms for restoring critical bone defects in plastic or orthopedic clinics is systematically reviewed and summarized. These strategies pave the way for the design of biomimetic bone substitutes for effective bone reconstruction with good biosafety. This review provides novel insights into the development and current trends of research on GelMA-based hydrogels as effective bone tissue engineering (BTE) scaffolds for correcting bone defects, and these contents are summarized and emphasized from various perspectives (osteoconductivity, vascularization, osteoinduction and 3D-bioprinting). In addition, advantages and deficiencies of GelMA-based bone substitutes used for bone regeneration are put forward, and corresponding improvement measures are presented prior to their clinical application in near future (created with BioRender.com).

Adaptation of Vascular Smooth Muscle Cell to Degradable Metal Stent Implantation

Iron-, magnesium-, or zinc-based metal vessel stents support vessel expansion at the period early after implantation and degrade away after vascular reconstruction, eliminating the side effects due to the long stay of stent implants in the body and the risks of restenosis and neoatherosclerosis. However, emerging evidence has indicated that their degradation alters the vascular microenvironment and induces adaptive responses of surrounding vessel cells, especially vascular smooth muscle cells (VSMCs). VSMCs are highly flexible cells that actively alter their phenotype in response to the stenting, similarly to what they do during all stages of atherosclerosis pathology, which significantly influences stent performance. This Review discusses how biodegradable metal stents modify vascular conditions and how VSMCs respond to various chemical, biological, and physical signals attributable to stent implantation. The focus is placed on the phenotypic adaptation of VSMCs and the clinical complications, which highlight the importance of VSMC transformation in future stent design.

Improving Biocompatibility for Next Generation of Metallic Implants

The increasing need for joint replacement surgeries, musculoskeletal repairs, and orthodontics worldwide prompts emerging technologies to evolve with healthcare's changing landscape. Metallic orthopaedic materials have a shared application history with the aerospace industry, making them only partly efficient in the biomedical domain. However, suitability of metallic materials in bone tissue replacements and regenerative therapies remains unchallenged due to their superior mechanical properties, eventhough they are not perfectly biocompatible. Therefore, exploring ways to improve biocompatibility is the most critical step toward designing the next generation of metallic biomaterials. This review discusses methods of improving biocompatibility of metals used in biomedical devices using surface modification, bulk modification, and incorporation of biologics. Our investigation spans multiple length scales, from bulk metals to the effect of microporosities, surface nanoarchitecture, and biomolecules such as DNA incorporation for enhanced biological response in metallic materials. We examine recent technologies such as 3D printing in alloy design and storing surface charge on nanoarchitecture surfaces, metal-on-metal, and ceramic-on-metal coatings to present a coherent and comprehensive understanding of the subject. Finally, we consider the advantages and challenges of metallic biomaterials and identify future directions.

Advances in the development of biodegradable coronary stents: A translational perspective

Implantation of cardiovascular stents is an important therapeutic method to treat coronary artery diseases. Bare-metal and drug-eluting stents show promising clinical outcomes, however, their permanent presence may create complications. In recent years, numerous preclinical and clinical trials have evaluated the properties of bioresorbable stents, including polymer and magnesium-based stents. Three-dimensional (3D) printed-shape-memory polymeric materials enable the self-deployment of stents and provide a novel approach for individualized treatment. Novel bioresorbable metallic stents such as iron- and zinc-based stents have also been investigated and refined. However, the development of novel bioresorbable stents accompanied by clinical translation remains time-consuming and challenging. This review comprehensively summarizes the development of bioresorbable stents based on their preclinical/clinical trials and highlights translational research as well as novel technologies for stents (e.g., bioresorbable electronic stents integrated with biosensors). These findings are expected to inspire the design of novel stents and optimization approaches to improve the efficacy of treatments for cardiovascular diseases.

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Bioresorbable stents can overcome the limitations of non-degradable stents.

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3D printing of shape-memory polymeric stents can lead to better clinical outcomes.

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Advances in Mg-, Fe- and Zn-based stents from a translational perspective.

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Electronic stents integrated with biosensors can covey stent status in real time.

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Development in the assessment of stent performance in vivo.

Bioresorbable vascular metallic scaffolds: Current status and research trends

To combat the long-term side effects associated with present-generation drug-eluting stents and provide opportunities for repeat scaffolding of plaqued arteries and treatment of coarctation of the aorta in infants and children, a new generation of bioresorbable stents has been introduced. Stents made of bioresorbable materials are corroded and absorbed by the body after completing their task as vascular scaffolding, allowing the stented arteries to restore their normal function. The concept is achieved by engineering stents that retain mechanical properties and integrity for at least 6-12 months before being broken down, metabolized, and harmlessly excreted by the body, leaving the treated vessel with a healthy endothelium, normal vasomotion, and free of the implant. In this article, the authors briefly review the development status of bioresorbable materials for stenting applications, their mechanical properties, and behavior in the vascular environment. Emphasis is given to new materials and under-explored research directions including long-term biocompatibility and emerging designs of bioactive stents. The goal for next-generation bioresorbable metals is the controlled release of therapeutic metal ions that could eliminate the need for anti-inflammatory drug-eluting coatings, characteristic of current-generation biostable stent metal scaffolds.

Modification of Biocorrosion and Cellular Response of Magnesium Alloy WE43 by Multiaxial Deformation

The study shows that multiaxial deformation (MAD) treatment leads to grain refinement in magnesium alloy WE43. Compared to the initial state, the MAD-processed alloy exhibited smoother biocorrosion dynamics in a fetal bovine serum and in a complete cell growth medium. Examination by microCT demonstrated retardation of the decline in the alloy volume and the Hounsfield unit values. An attendant reduction in the rate of accumulation of the biodegradation products in the immersion medium, a less pronounced alkalization, and inhibited sedimentation of biodegradation products on the surface of the alloy were observed after MAD. These effects were accompanied with an increase in the osteogenic mesenchymal stromal cell viability on the alloy surface and in a medium containing their extracts. It is expected that the more orderly dynamics of biodegradation of the WE43 alloy after MAD and the stimulation of cell colonization will effectively promote stable osteosynthesis, making repeat implant extraction surgeries unnecessary.

Investigation on tribological behaviors of biodegradable pure Zn and Zn-X (Li, Cu, Ge) binary alloys

As a potential biodegradable implant material, zinc (Zn) alloys have attracted increasing attention due to their good biocompatibility and moderate degradation rate. Zn and its alloys are expected to become candidate materials for medical devices. The metals implanted in the human body will inevitably undergo friction in the human body before it is completely degraded. Friction and wear are essential factors which may cause medical devices' service failure. However, there are still few studies on the friction and wear properties of biodegradable Zn-based alloys in the human body, and most studies just focus on the mechanical properties, degradation properties and biocompatibility of the alloys. Thus, it is crucial to study the friction and wear properties of Zn and its alloys. In the present work, we investigated the tribological properties of biodegradable pure Zn and Zn-X (Li, Cu, Ge) alloys. Our study found that under simulated body fluid and dry friction conditions, the addition of alloying elements Li and Cu can improve the friction properties of Zn. Among the four metals, Zn-0.5Li alloy has the lowest friction coefficient and the best wear resistance. Hank's solution has lubricating and corrosive effects. That is to say, when the alloy is rubbed in Hank's solution, it can not only be protected by the lubrication of the solution, but also tribocorrosion will occur as well.

The effects of a biodegradable Mg-based alloy on the function of VSMCs via immunoregulation of macrophages through Mg-induced responses

Background

Restenosis is one of the worst side effects of percutaneous coronary intervention (PCI) due to neointima formation resulting from the excessive proliferation and migration of vascular smooth muscle cells (VSMCs) and continuous inflammation. Biodegradable Mg-based alloy is a promising candidate material because of its good mechanical properties and biocompatibility, and biodegradation of cardiovascular stents. Although studies have shown reduced neointima formation after Mg-based CVS implantation in vivo, these findings were inconsistent with in vitro studies, demonstrating magnesium-mediated promotion of the proliferation and migration of VSMCs. Given the vital role of activated macrophage-driven inflammation in neointima formation, along with the well-demonstrated crosstalk between macrophages and VSMCs, we investigated the interactions of a biodegradable Mg-Nd-Zn-Zr alloy (denoted JDBM), which is especially important for cardiovascular stents, with VSMCs via macrophages.

Methods

JDBM extracts and MgCl₂ solutions were prepared to study their effect on macrophages. To study the effects of the JDBM extracts and MgCl₂ solutions on the function of VSMCs via immunoregulation of macrophages, conditioned media (CM) obtained from macrophages was used to establish a VSMC-macrophage indirect coculture system.

Results

Our results showed that both JDBM extracts and MgCl₂ solutions significantly attenuated the inflammatory response stimulated by lipopolysaccharide (LPS)-activated macrophages and converted macrophages into M2-type cells. In addition, JDBM extracts and MgCl₂ solutions significantly decreased the expression of genes related to VSMC phenotypic switching, migration, and proliferation in macrophages. Furthermore, the proliferation, migration, and proinflammatory phenotypic switching of VSMCs were significantly inhibited when the cells were incubated with CMs from macrophages treated with LPS + extracts or LPS + MgCl₂ solutions.

Conclusions

Taken together, our results suggested that the magnesium in the JDBM extract could affect the functions of VSMCs through macrophage-mediated immunoregulation, inhibiting smooth muscle hyperproliferation to suppress restenosis after implantation of a biodegradable Mg-based stent.

Capturing Magnesium Ions via Microfluidic Hydrogel Microspheres for Promoting Cancellous Bone Regeneration

Metal ions are important trace elements in the human body, which directly affect the human metabolism and the regeneration of damaged tissues. For instance, the advanced combination of magnesium ions (Mg²⁺) and bone repair materials make the composite materials have the function of promoting vascular repair and enhancing the adhesion of osteoblasts. Herein, inspired by magnets to attract metals, we utilized the coordination reaction of metal ion ligand to construct a bisphosphonate-functionalized injectable hydrogel microsphere (GelMA-BP-Mg) which could promote cancellous bone reconstruction of osteoporotic bone defect via capturing Mg²⁺. By grafting bisphosphonate (BP) on GelMA microspheres, GelMA-BP microspheres could produce powerful Mg²⁺ capture ability and sustained release performance through coordination reaction, while sustained release BP has bone-targeting properties. In the injectable GelMA-BP-Mg microsphere system, the atomic percentage of captured Mg²⁺ was 0.6%, and the captured Mg²⁺ could be effectively released for 18 days. These proved that the composite microspheres could effectively capture Mg²⁺ and provided the basis for the composite microspheres to activate osteoblasts and endothelial cells and inhibit osteoclasts. Both in vivo and in vitro experimental results revealed that the magnet-inspired Mg²⁺-capturing composite microspheres are beneficial to osteogenesis and angiogenesis by stimulating osteoblasts and endothelial cells while restraining osteoclasts, and ultimately effectively promote cancellous bone regeneration. This study could provide some meaningful conceptions for the treatment of osteoporotic bone defects on the basis of metal ions.

Comparison of in Vascular Bioreactors and In Vivo Models of Degradation and Cellular Response of Mg-Zn-Mn Stents

Traditional in vitro evaluation criteria of magnesium (Mg)-based stents cannot reflect the degradation process in vivo, due to the interdependence and interference between biodegradable properties and bioenvironment. The current direct and indirect evaluation approaches of in vitro biocompatibility do not have a hydrodynamic environment and vascular biological structure existing in vivo. Herein, we designed a vascular bioreactor to provide an ex vivo culture environment for vessels, which reveals the degradation behavior of Mg-Zn-Mn stent and the effect of its degradation on cells. We reported that rabbit carotid arteries could maintain native morphology and viability in the bioreactor under the best condition within a flow rate of 5.4 mL min^-1 and a culture time of one week. With this culture condition, Mg-Zn-Mn stents were implanted into the arteries in the bioreactors and compared with in vivo rabbit models. The arteries maintained cell survival in the bioreactor, but the cell attachment was absent on the stent struts, associated with a fast degradation. Conversely, the stents achieved a rapid and complete endothelialization in vivo for two weeks. This study could provide a correlation and difference of the degradation behavior and cellular response to the degradation of Mg-based stent between ex vivo and in vivo approaches.

Investigating the stress corrosion cracking of a biodegradable Zn-0.8 wt%Li alloy in simulated body fluid

Stress corrosion cracking (SCC) may lead to brittle, unexpected failure of medical devices. However, available researches are limited to Mg-based biodegradable metals (BM) and pure Zn. The stress corrosion behaviors of newly-developed Zn alloys remain unclear. In the present work, we conducted slow strain rate testing (SSRT) and constant-load immersion test on a promising Zn-0.8 wt%Li alloy in order to investigate its SCC susceptibility and examine its feasibility as BM with pure Zn as control group. We observed that Zn-0.8 wt%Li alloy exhibited low SCC susceptibility. This was attributed to variations in microstructure and deformation mechanism after alloying with Li. In addition, both pure Zn and Zn-0.8 wt%Li alloy did not fracture over a period of 28 days during constant-load immersion test. The magnitude of applied stress was close to physiological condition and thus, we proved the feasibility of both materials as BM.

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The deformation mechanisms of pure Zn and Zn-0.8 wt%Li alloy were different.

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For pure Zn, surface curvatures provided sites for SCC initiation.

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Only shallow cracks on corrosion layer were observed for Zn-0.8 wt%Li alloy.

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Both materials did not fracture after constant-load immersion test.

Salt Preform Texturing of Absorbable Zn Substrates for Bone-implant Applications

Surface roughness is an important factor in improving the bone-implant contact area to enhance bone regeneration, yet this aspect has not been applied to absorbable metals. Textured zinc surfaces with varying degrees of surface roughness were produced using a salt-preform method with fine- and coarse-grained salts and compared to a polished control sample. The resulting surfaces were characterized by scanning electron microscopy (SEM), surface roughness, corrosion rates, and in vitro cytotoxicity. The resulting textured surfaces exhibit micron-sized cavities and increased roughness consistent with the initial salt particle size. The corrosion rate was shown to accelerate significantly as compared to the polished control sample, and pre-osteoblasts displayed healthy morphologies on the textures. The results confirm textured zinc surfaces support cell adhesion and can be used to control the corrosion rate. This study represents an important intermediate step that can be applied to porous absorbable metal scaffolds for bone-implant applications.

A surface-engineered multifunctional TiO2 based nano-layer simultaneously elevates the corrosion resistance, osteoconductivity and antimicrobial property of a magnesium alloy

Magnesium biometals exhibit great potentials for orthopeadic applications owing to their biodegradability, bioactive effects and satisfactory mechanical properties. However, rapid corrosion of Mg implants in vivo combined with large amount of hydrogen gas evolution is harmful to bone healing process which seriously confines their clinical applications. Enlightened by the superior biocompatibility and corrosion resistance of passive titanium oxide layer automatically formed on titanium alloy, we employ the Ti and O dual plasma ion immersion implantation (PIII) technique to construct a multifunctional TiO₂ based nano-layer on ZK60 magnesium substrates for enhanced corrosion resistance, osteoconductivity and antimicrobial activity. The constructed nano-layer (TiO₂/MgO) can effectively suppress degradation rate of ZK60 substrates in vitro and still maintain 94% implant volume after post-surgery eight weeks. In animal study, a large amount of bony tissue with increased bone mineral density and trabecular thickness is formed around the PIII treated group in post-operation eight weeks. Moreover, the newly formed bone in the PIII treated group is well mineralized and its mechanical property almost restores to the level of that of surrounding mature bone. Surprisingly, a remarkable killing ratio of 99.31% against S. aureus can be found on the PIII treated sample under ultra-violet (UV) irradiation which mainly attributes to the oxidative stress induced by the reactive oxygen species (ROS). We believe that this multifunctional TiO₂ based nano-layer not only controls the degradation of magnesium implant, but also regulates its implant-to-bone integration effectively. STATEMENT OF SIGNIFICANCE: Rapid corrosion of magnesium implants is the major issue for orthopaedic applications. Inspired by the biocompatibility and corrosion resistance of passive titanium oxide layer automatically formed on titanium alloy, we construct a multifunctional TiO₂/MgO nanolayer on magnesium substrates to simultaneously achieve superior corrosion resistance, satisfactory osteoconductivity in rat intramedullary bone defect model and excellent antimicrobial activity against S. aureus under UV irradiation. The current findings suggest that the specific TiO₂/MgO nano-layer on magnesium surface can achieve the three objectives aforementioned and we believe this study can demonstrate the potential of biodegradable metals for future clinical applications.

The Future of Cardiovascular Stents: Bioresorbable and Integrated Biosensor Technology

Cardiovascular disease is the greatest cause of death worldwide. Atherosclerosis is the underlying pathology responsible for two thirds of these deaths. It is the age-dependent process of "furring of the arteries." In many scenarios the disease is caused by poor diet, high blood pressure, and genetic risk factors, and is exacerbated by obesity, diabetes, and sedentary lifestyle. Current pharmacological anti-atherosclerotic modalities still fail to control the disease and improvements in clinical interventions are urgently required. Blocked atherosclerotic arteries are routinely treated in hospitals with an expandable metal stent. However, stented vessels are often silently re-blocked by developing "in-stent restenosis," a wound response, in which the vessel's lumen renarrows by excess proliferation of vascular smooth muscle cells, termed hyperplasia. Herein, the current stent technology and the future of biosensing devices to overcome in-stent restenosis are reviewed. Second, with advances in nanofabrication, new sensing methods and how researchers are investigating ways to integrate biosensors within stents are highlighted. The future of implantable medical devices in the context of the emerging "Internet of Things" and how this will significantly influence future biosensor technology for future generations are also discussed.

Enhanced cytocompatibility and antibacterial property of zinc phosphate coating on biodegradable zinc materials

Zinc (Zn) has recently emerged as a promising biodegradable metal thanks to its critical physiological roles and promising degradation behavior. However, cytocompatibility and antibacterial property of Zn is still suboptimal, in part, due to the excessive Zn ions released during degradation. Inspired by the calcium phosphate-based minerals in natural bone tissue, zinc phosphate (ZnP) coatings were prepared on pure Zn using a chemical conversion method in this study. The coating morphology was then optimized through controlling the pH of coating solution, resulting in a homogeneous micro-/nano-ZnP coating structure. The ZnP coating significantly increased the cell viability, adhesion, and differentiation of pre-osteoblasts and vascular endothelial cells, while significantly reduced the adhesion of the platelets and E. coli. Additionally, ZnP coating significantly reduced the Zn ion release from the bulk material during degradation process, resulting in a much lower Zn2+ concentration and pH change in the surrounding environment. The improved hemocompatibility, cytocompatibility and antibacterial performance of ZnP coated Zn biomaterials could be mainly attributed to the controlled Zn ion release and micro-/nano-scaled coating structure. Taken together, ZnP coating on Zn-based biomaterial appears to be a viable approach to enhance its biocompatibility and antibacterial property as well as to control its degradation rate. Statement of Significance Zn and its alloys are promising biodegradable implant materials for orthopedic and cardiovascular applications. However, notable cytotoxicity has been reported due to degradation products accumulated in the local environment, largely overdosed Zn2+. Thus, controlling burst Zn2+ release is the key to minimize the toxicity of Zn implants. To achieve this goal, we prepared a homogenous ZnP coating on Zn metals thanks to its easy synthesis, stable chemical property, and good biocompatibility. Results showed that ZnP not only improved the cell viability, adhesion and proliferation, but also significantly reduced the attachment of platelet and bacterial. Therefore, ZnP could be a promising approach to improve the functional performance of Zn-based implants, and potentially be applied to many other medical implants.

Improved corrosion resistance of commercially pure magnesium after its modification by plasma electrolytic oxidation with organic additives

The optimal mechanical properties render magnesium widely used in industrial and biomedical applications. However, magnesium is highly reactive and unstable in aqueous solutions, which can be modulated to increase stability of reactive metals that include the use of alloys or by altering the surface with coatings. Plasma electrolytic oxidation is an efficient and tuneable method to apply a surface coating. By varying the plasma electrolytic oxidation parameters voltage, current density, time and (additives in the) electrolytic solution, the morphology, composition and surface energy of surface coatings are set. In the present study, we evaluated the influence on surface coatings of two solute additives, i.e. hexamethylenetetramine and mannitol, to base solutes silicate and potassium hydroxide. Results from in vitro studies in NaCl demonstrated an improvement in the corrosion resistance. In addition, coatings were obtained by a two-step anodization procedure, firstly anodizing in an electrolyte solution containing sodium fluoride and secondly in an electrolyte solution with hexamethylenetetramine and mannitol, respectively. Results showed that the first layer acts as a protective layer which improves the corrosion resistance in comparison with the samples with a single anodizing step. In conclusion, these coatings are promising candidates to be used in biomedical applications in particular because the components are non-toxic for the body and the rate of degradation of the surface coating is lower than that of pure magnesium.

Interfacial Zinc Phosphate is the Key to Controlling Biocompatibility of Metallic Zinc Implants

Recently emerged metallic zinc (Zn) is a new generation of promising candidates for bioresorbable medical implants thanks to its essential physiological relevance, mechanical strength, and more matched degradation pace to that of tissue healing. Zn-based metals exhibit excellent biocompatibility in various animal models. However, direct culture of cells on Zn metals yields surprisingly low viability, indicating high cytotoxicity of Zn. This contradicting phenomenon should result from the different degradation mechanisms between in vitro and in vivo. To solve this puzzle, the roles of all major players, i.e., zinc phosphate (ZnP), zinc oxide (ZnO), zinc hydroxide (Zn(OH)2), pH, and Zn2+, which are involved in the degradation process are examined. Data shows that ZnP, not ZnO or Zn(OH)2, significantly enhances its biocompatibility. The mild pH change during degradation also has no significant impact on cell viability. Collectively, ZnP appears to be the key to controlling the biocompatibility of Zn implants and could be applied as a novel surface coating to improve biocompatibility of different implants.

Mechanical Strength, Biodegradation, and in Vitro and in Vivo Biocompatibility of Zn Biomaterials

Zn-based biomaterials have emerged as promising new types of bioresorbable metallics applicable to orthopedic devices, cardiovascular stents, and other medical applications recently. Compared to other degradable metallic biomaterials (i.e., Mg- or Fe-based), Zn biomaterials have a more appropriate corrosion rate without hydrogen gas evolution. Here, we evaluated the potential of Zn-based metallics as medical implants, both in vitro and in vivo, alongside a standard benchmark Mg alloy, AZ31. The mechanical properties of the pure Zn were not strong enough but were significantly enhanced (microhardness > 70 kg/mm², strength > 220 MPa, elongation > 15%) after alloying with Sr or Mg (1.5 at. %), surpassing the minimal design criteria for load-bearing device applications. The corrosion rate of Zn-based biomaterials was about 0.4 mm/year, significantly slower than that of AZ31. The measured cell viability and proliferation of three different human primary cells fared better for Zn-based biomaterials than AZ31 using both direct and indirect culture methods. Platelet adhesion and activation on Zn-based materials were minimal, significantly less than on AZ31. The hemolysis ratio of red cells (<0.5%) after incubation with Zn-based materials was also well below the ISO standard of 5%. Moreover, Zn-based biomaterials promoted stem cell differentiation to induce the extracellular matrix mineralization process. In addition, in vivo animal testing using subcutaneous, bone, and vascular implantations revealed that the acute toxicity and immune response of Zn-based biomaterials were minimal/moderate, comparable to that of AZ31. No extensive cell death and foreign body reactions were observed. Taken together, Zn-based biomaterials may have a great potential as promising candidates for medical implants.

Effect of magnesium particle fraction on osteoinduction of hydroxyapatite sphere-based scaffolds

HAs-30Mg (incorporation of 30% Mg into HA sphere-based scaffolds) induced the optimum new bone formation.

The Effect of Surface Treatments on the Degradation of Biomedical Mg Alloys-A Review Paper

This report reviews the effects of chemical, physical, and mechanical surface treatments on the degradation behavior of Mg alloys via their influence on the roughness and surface morphology. Many studies have been focused on technically-used AZ alloys and a few investigations regarding the surface treatment of biodegradable and Al-free Mg alloys, especially under physiological conditions. These treatments tailor the surface roughness, homogenize the morphology, and decrease the degradation rate of the alloys. Conversely, there have also been reports which showed that rough surfaces lead to less pitting and good cell adherence. Besides roughness, there are many other parameters which are much more important than roughness when regarding the degradation behavior of an alloy. These studies, which indicate the relationship between surface treatments, roughness and degradation, require further elaboration, particularly for biomedical Mg alloy applications.

A new corrosion-inhibiting strategy for biodegradable magnesium: reduced nicotinamide adenine dinucleotide (NADH)

Utilization of biodegradable metals in biomedical fields is emerging because it avoids high-risk and uneconomic secondary surgeries for removing implantable devices. Mg and its alloys are considered optimum materials for biodegradable implantable devices because of their high biocompatibility; however, their excessive and uncontrollable biodegradation is a difficult challenge to overcome. Here, we present a novel method of inhibiting Mg biodegradation by utilizing reduced nicotinamide adenine dinucleotide (NADH), an endogenous cofactor present in all living cells. Incorporating NADH significantly increases Mg corrosion resistance by promoting the formation of thick and dense protective layers. The unique mechanism by which NADH enables corrosion inhibition was discovered by combined microscopic and spectroscopic analyses. NADH is initially self-adsorbed onto the surface of Mg oxide layers, preventing Cl⁻ ions from dissolving Mg oxides, and later recruits Ca²⁺ ions to form stable Ca-P protective layers. Furthermore, stability of NADH as a corrosion inhibitor of Mg under physiological conditions were confirmed using cell tests. Moreover, excellent cell adhesion and viability to Mg treated with NADH shows the feasibility of introduction of NADH to Mg-based implantable system. Our strategy using NADH suggests an interesting new way of delaying the degradation of Mg and demonstrates potential roles for biomolecules in the engineering the biodegradability of metals.

Fabrication, microstructure, and properties of a biodegradable Mg-Zn-Ca clip

An Mg-Zn-Ca alloy biodegradable clip was fabricated by combining hot extrusion and blanking processing. Microstructure evolution was investigated by optical microscopy and electron backscattering diffraction and the occlusion properties of Mg-Zn-Ca alloy clip were evaluated in vitro and in vivo. It was found that the as-extruded Mg-Zn-Ca alloy exhibited a typical fiber microstructure. After blanking, the basal texture intensity increased because of the work hardening effect. Subsequent annealing treatment of the blanking clip can significantly weaken the texture while improving the ductility of the Mg-Zn-Ca alloy. It was found that Mg-Zn-Ca clips can maintain closure performance for 2 weeks in in vitro immersion tests while in vivo tests indicated that the Mg-3Zn-0.2Ca alloy clips fabricated by this preparation processing successfully occluded the blood vessels. These results suggest that the developed Mg-3Zn-0.2Ca alloy clip is a suitable candidate for biodegradable soft tissue fixation devices such as surgical clips. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1741-1749, 2019.

Layered double hydroxide/poly-dopamine composite coating with surface heparinization on Mg alloys: improved anticorrosion, endothelialization and hemocompatibility

Magnesium (Mg) and its alloys are promising cardiovascular stent materials due to their favourable physical properties and complete degradation in vivo. However, rapid degradation and poor cytocompatibility hinder their clinical applications. To enhance the corrosion resistance and endothelialization of the AZ31 alloy, a layered double hydroxide (LDH)/poly-dopamine (PDA) composite coating (LDH/PDA) was successfully fabricated. Polarization curves and the electrochemical impedance spectroscopy Nyquist spectrum test proved that the corrosion resistance of the LDH/PDA sample was significantly improved in vitro. The LDH/PDA sample greatly improved the adherence process and the proliferation rate of human umbilical vein endothelial cells (HUVECs). After culturing for 10 days, the number of living HUVECs on the LDH/PDA sample was comparable to that on the Ti sample whereas the cells barely survived on the AZ31 or LDH coating. Furthermore, heparin was immobilized on LDH/PDA via a covalent bond (LDH/PDA/HEP). The corrosion resistance and long-term proliferation of HUVECs after the introduction of heparin were mildly decreased compared with the L/P sample, but were still greatly improved compared with AZ31, the LDH coating and the PDA coating. Furthermore, the LDH/PDA/HEP sample greatly improved the HUVEC migration rate compared with the LDH/PDA sample, and inhibited platelet adhesion which was intense on the LDH/PDA sample. Both LDH/PDA and LDH/PDA/HEP samples had a low hemolysis rate (2.52% and 0.65%, respectively) in vitro and eliminated the adverse biocompatible effects of the direct PDA coating on the AZ31 substrate in vivo. Our results suggest that the LDH/PDA composite coating with further heparinization is a promising method to modify the surface of Mg alloys by significantly improving corrosion resistance, endothelialization and hemocompatibility.

Bio-Functional Design, Application and Trends in Metallic Biomaterials

Introduction of metals as biomaterials has been known for a long time. In the early development, sufficient strength and suitable mechanical properties were the main considerations for metal implants. With the development of new generations of biomaterials, the concepts of bioactive and biodegradable materials were proposed. Biological function design is very import for metal implants in biomedical applications. Three crucial design criteria are summarized for developing metal implants: (1) mechanical properties that mimic the host tissues; (2) sufficient bioactivities to form bio-bonding between implants and surrounding tissues; and (3) a degradation rate that matches tissue regeneration and biodegradability. This article reviews the development of metal implants and their applications in biomedical engineering. Development trends and future perspectives of metallic biomaterials are also discussed.

Bioabsorbable zinc ion induced biphasic cellular responses in vascular smooth muscle cells

Bioabsorbable metal zinc (Zn) is a promising new generation of implantable scaffold for cardiovascular and orthopedic applications. In cardiovascular stent applications, zinc ion (Zn²⁺) will be gradually released into the surrounding vascular tissues from such Zn-containing scaffolds after implantation. However, the interactions between vascular cells and Zn²⁺ are still largely unknown. We explored the short-term effects of extracellular Zn²⁺ on human smooth muscle cells (SMCs) up to 24 h, and an interesting biphasic effect of Zn²⁺ was observed. Lower concentrations (<80 μM) of Zn²⁺ had no adverse effects on cell viability but promoted cell adhesion, cell spreading, cell proliferation, cell migration, and enhanced the expression of F-actin and vinculin. Cells treated with such lower concentrations of Zn²⁺ displayed an elongated shape compared to controls without any treatment. In contrast, cells treated with higher Zn²⁺ concentrations (80–120 μM) had opposite cellular responses and behaviors. Gene expression profiles revealed that the most affected functional genes were related to angiogenesis, inflammation, cell adhesion, vessel tone, and platelet aggregation. Results indicated that Zn has interesting concentration-dependent biphasic effects on SMCs with low concentrations being beneficial to cellular functions.