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Feng C, Huang C, Huang J, Yang X, Liu Y, Shuai Z, Dong J, Ren T, Wang B. Preparation of healing-promoting and fibrosis-inhibiting asymmetric poly(ethylene glycol-b-L-phenylalanine)/cRGD-modified hyaluronate sponges and their applications in hemorrhage and nasal mucosa repair. Int J Biol Macromol 2024; 258:128911. [PMID: 38141717 DOI: 10.1016/j.ijbiomac.2023.128911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
Acute or chromic bleeding, such as epistaxis, requires hemostatic materials to assist hemostasis. Even in complex cases, hemostatic materials must have other functions, including the promotion of healing and prevention of adhesion. Herein, a series of fibrosis-suppressive functional cRGD-modified crosslinking hyaluronic acid sponges were prepared. The in vitro hemostatic efficiency and mechanism were determined using blood clotting time, blood coagulation index, lactate dehydrogenase (LDH) and thromboxane B2 (TX-B2) ELISA, and proteomics. Among the prepared sponges, both poly(ethylene-b-L-Phe) (PEBP)-and cRGD contained SPN4 and exhibited the highest platelet concentration and activation efficiency as well as the most effective coagulative effect. In addition, no significant cytotoxicity was observed for the sponges in rat airway epithelial cells. The in vivo hemostatic and adhesion-preventive effects of the sponges were evaluated using rat models of liver injury and sidewall defect-cecum abrasion. PEBP-containing sponges effectively prevented postoperative adhesion and cRGD-modified sponges exhibited excellent hemostatic effects. Finally, the comprehensive repair effects of the sponges were evaluated using a rabbit maxillary sinus mucosal injury model, based on CT, MRI examination, and pathological staining. SPN4 exhibited the best comprehensive reparative effects, including the promotion of mucosal repair and infection inhibition. Thus, SPN4 is a promising multifunctional hemostatic material.
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Affiliation(s)
- Chengmin Feng
- Department of Otolaryngology Head and Neck Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Changlin Huang
- Department of Chemistry, School of Pharmacy, North Sichuan Medical College, Nanchong 637000, China
| | - Jing Huang
- Department of Otolaryngology Head and Neck Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China; Department of Otolaryngology Head and Neck Surgery, School of Clinical Medicine, North Sichuan Medical College, 637000 Nanchong, China
| | - Xiaomei Yang
- Department of Otolaryngology Head and Neck Surgery, School of Clinical Medicine, North Sichuan Medical College, 637000 Nanchong, China
| | - Yuting Liu
- Department of Chemistry, School of Pharmacy, North Sichuan Medical College, Nanchong 637000, China
| | - Zheyu Shuai
- Department of Chemistry, School of Pharmacy, North Sichuan Medical College, Nanchong 637000, China
| | - Jun Dong
- Department of Chemistry, School of Pharmacy, North Sichuan Medical College, Nanchong 637000, China
| | - Tongyan Ren
- Department of Chemistry, School of Pharmacy, North Sichuan Medical College, Nanchong 637000, China
| | - Bing Wang
- Department of Chemistry, School of Pharmacy, North Sichuan Medical College, Nanchong 637000, China.
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Hao D, Lin J, Liu R, Pivetti C, Yamashiro K, Schutzman LM, Sageshima J, Kwong M, Bahatyrevich N, Farmer DL, Humphries MD, Lam KS, Panitch A, Wang A. A bio-instructive parylene-based conformal coating suppresses thrombosis and intimal hyperplasia of implantable vascular devices. Bioact Mater 2023; 28:467-479. [PMID: 37408799 PMCID: PMC10318457 DOI: 10.1016/j.bioactmat.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/17/2023] [Accepted: 06/19/2023] [Indexed: 07/07/2023] Open
Abstract
Implantable vascular devices are widely used in clinical treatments for various vascular diseases. However, current approved clinical implantable vascular devices generally have high failure rates primarily due to their surface lacking inherent functional endothelium. Here, inspired by the pathological mechanisms of vascular device failure and physiological functions of native endothelium, we developed a new generation of bioactive parylene (poly(p-xylylene))-based conformal coating to address these challenges of the vascular devices. This coating used a polyethylene glycol (PEG) linker to introduce an endothelial progenitor cell (EPC) specific binding ligand LXW7 (cGRGDdvc) onto the vascular devices for preventing platelet adhesion and selectively capturing endogenous EPCs. Also, we confirmed the long-term stability and function of this coating in human serum. Using two vascular disease-related large animal models, a porcine carotid artery interposition model and a porcine carotid artery-jugular vein arteriovenous graft model, we demonstrated that this coating enabled rapid generation of self-renewable "living" endothelium on the blood contacting surface of the expanded polytetrafluoroethylene (ePTFE) grafts after implantation. We expect this easy-to-apply conformal coating will present a promising avenue to engineer surface properties of "off-the-shelf" implantable vascular devices for long-lasting performance in the clinical settings.
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Affiliation(s)
- Dake Hao
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA, 95817, United States
| | - Jonathan Lin
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Ruiwu Liu
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Christopher Pivetti
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA, 95817, United States
| | - Kaeli Yamashiro
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Linda M. Schutzman
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Junichiro Sageshima
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Mimmie Kwong
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Nataliya Bahatyrevich
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Diana L. Farmer
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA, 95817, United States
| | - Misty D. Humphries
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Kit S. Lam
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
| | - Alyssa Panitch
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, 30332, United States
- Department of Biomedical Engineering, University of California Davis, Davis, CA, 95616, United States
| | - Aijun Wang
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA, 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA, 95817, United States
- Department of Biomedical Engineering, University of California Davis, Davis, CA, 95616, United States
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Gutowski P, Guziewicz M, Ilzecki M, Kazimierczak A, Lawson JH, Prichard HL, Przywara S, Samad R, Tente W, Turek J, Witkiewicz W, Zapotoczny N, Zubilewicz T, Niklason LE. Six-year outcomes of a phase II study of human-tissue engineered blood vessels for peripheral arterial bypass. JVS Vasc Sci 2023; 4:100092. [PMID: 36874956 PMCID: PMC9976461 DOI: 10.1016/j.jvssci.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/08/2022] [Indexed: 12/05/2022] Open
Abstract
Objective The human acellular vessel (HAV) was evaluated for surgical bypass in a phase II study. The primary results at 24 months after implantation have been reported, and the patients will be evaluated for ≤10 years. Methods In the present report, we have described the 6-year results of a prospective, open-label, single-treatment arm, multicenter study. Patients with advanced peripheral artery disease (PAD) requiring above-the-knee femoropopliteal bypass surgery without available autologous graft options had undergone implantation with the HAV, a bioengineered human tissue replacement blood vessel. The patients who completed the 24-month primary portion of the study will be evaluated for ≤10 years after implantation. The present mid-term analysis was performed at the 6-year milestone (72 months) for patients followed up for 24 to 72 months. Results HAVs were implanted in 20 patients at three sites in Poland. Seven patients had discontinued the study before completing the 2-year portion of the study: four after graft occlusion had occurred and three who had died of causes deemed unrelated to the conduit, with the HAV reported as functional at their last visit. The primary results at 24 months showed primary, primary assisted, and secondary patency rates of 58%, 58%, and 74%, respectively. One vessel had developed a pseudoaneurysm deemed possibly iatrogenic; no other signs of structural failure were reported. No rejections or infections of the HAV occurred, and no patient had required amputation of the implanted limb. Of the 20 patients, 13 had completed the primary portion of the study; however, 1 patient had died shortly after 24 months. Of the remaining 12 patients, 3 died of causes unrelated to the HAV. One patient had required thrombectomy twice, with secondary patency achieved. No other interventions were recorded between 24 and 72 months. At 72 months, five patients had a patent HAV, including four patients with primary patency. For the entire study population from day 1 to month 72, the overall primary, primary assisted, and secondary patency rate estimated using Kaplan-Meier analysis was 44%, 45%, and 60% respectively, with censoring for death. No patient had experienced rejection or infection of the HAV, and no patient had required amputation of the implanted limb. Conclusions The infection-resistant, off-the-shelf HAV could provide a durable alternative conduit in the arterial circuit setting to restore the lower extremity blood supply in patients with PAD, with remodeling into the recipient's own vessel over time. The HAV is currently being evaluated in seven clinical trials to treat PAD, vascular trauma, and as a hemodialysis access conduit.
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Affiliation(s)
- Piotr Gutowski
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Malgorzata Guziewicz
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Marek Ilzecki
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Arkadiusz Kazimierczak
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Jeffrey H. Lawson
- Humacyte, Inc, Durham, NC
- Department of Surgery, Duke University, Durham, NC
| | | | - Stanislaw Przywara
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Rabih Samad
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | | | - Jakub Turek
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Wojcieh Witkiewicz
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Norbert Zapotoczny
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Tomaz Zubilewicz
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Laura E. Niklason
- Humacyte, Inc, Durham, NC
- Department of Anesthesia and Biomedical Engineering, Yale University, New Haven
- Department of Biomedical Engineering, Yale University, New Haven, CT
- Correspondence: Laura E. Niklason, MD, PhD, Humacyte, Inc, 2525 NC-54, Durham, NC 27713
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Kakinoki S, Nishioka S, Arichi Y, Yamaoka T. Stable and direct coating of fibronectin-derived Leu-Asp-Val peptide on ePTFE using one-pot tyrosine oxidation for endothelial cell adhesion. Colloids Surf B Biointerfaces 2022; 216:112576. [PMID: 35636324 DOI: 10.1016/j.colsurfb.2022.112576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/30/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
Expanded polytetrafluoroethylene (ePTFE) is widely used in clinical applications, such as in the manufacture of blood-contacting implantable devices, owing to its flexibility, biostability, and non-adhesiveness. Modification with peptides is an effective strategy to further improve the ePTFE function. However, the chemical stability of PTFE makes it difficult to modify with peptides. In this study, we reported a simple method for the dense and stable coating of biofunctional peptides on the ePTFE surface through the anchor sequence, Tyr-Lys-Tyr-Lys-Tyr-Lys (YK3). A peptide (YK3-LDV) incorporating the YK3 anchor and a ligand sequence for α4β1 integrin, Leu-Asp-Val (LDV), was successfully coated on ePTFE grafts through one-pot oxidation. The peptide layer constructed via YK3-LDV coating on ePTFE was stable and resistant to extensive washing by aqueous solutions of highly concentrated salts and surfactants. YK3-LDV coating promoted the in vitro adhesion of endothelial cells to ePTFE. Furthermore, YK3-LDV coating accelerated the in vivo formation of neointima-like tissue in a rat model with an ePTFE patch implanted into the carotid artery.
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Affiliation(s)
- Sachiro Kakinoki
- Faculty of Chemistry, Materials and Bioengineering, Kansai University, 3-3-35 Yamate-cho, Suita, Osaka 564-0836, Japan; Organization for Research and Development of Innovative Science and Technology, Kansai University, 3-3-35 Yamate-cho, Suita, Osaka 564-0836, Japan; Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan.
| | - Satoru Nishioka
- Graduate School of Science and Engineering, Kansai University, 3-3-35 Yamate-cho, Suita, Osaka 564-0836, Japan
| | - Yuki Arichi
- Graduate School of Science and Engineering, Kansai University, 3-3-35 Yamate-cho, Suita, Osaka 564-0836, Japan
| | - Tetsuji Yamaoka
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan
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Abstract
Cardiovascular defects, injuries, and degenerative diseases often require surgical intervention and the use of implantable replacement material and conduits. Traditional vascular grafts made of synthetic polymers, animal and cadaveric tissues, or autologous vasculature have been utilized for almost a century with well-characterized outcomes, leaving areas of unmet need for the patients in terms of durability and long-term patency, susceptibility to infection, immunogenicity associated with the risk of rejection, and inflammation and mechanical failure. Research to address these limitations is exploring avenues as diverse as gene therapy, cell therapy, cell reprogramming, and bioengineering of human tissue and replacement organs. Tissue-engineered vascular conduits, either with viable autologous cells or decellularized, are the forefront of technology in cardiovascular reconstruction and offer many benefits over traditional graft materials, particularly in the potential for the implanted material to be adopted and remodeled into host tissue and thus offer safer, more durable performance. This review discusses the key advances and future directions in the field of surgical vascular repair, replacement, and reconstruction, with a focus on the challenges and expected benefits of bioengineering human tissues and blood vessels.
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Affiliation(s)
- Kaleb M. Naegeli
- Humacyte, Inc, Durham, NC (K.M.N., M.H.K., Y.L., J.W., E.A.H., L.E.N.)
| | - Mehmet H. Kural
- Humacyte, Inc, Durham, NC (K.M.N., M.H.K., Y.L., J.W., E.A.H., L.E.N.)
| | - Yuling Li
- Humacyte, Inc, Durham, NC (K.M.N., M.H.K., Y.L., J.W., E.A.H., L.E.N.)
| | - Juan Wang
- Humacyte, Inc, Durham, NC (K.M.N., M.H.K., Y.L., J.W., E.A.H., L.E.N.)
| | | | - Laura E. Niklason
- Department of Anesthesiology and Biomedical Engineering, Yale University, New Haven, CT (L.E.N.)
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Grajciarová M, Turek D, Malečková A, Pálek R, Liška V, Tomášek P, Králičková M, Tonar Z. Are ovine and porcine carotid arteries equivalent animal models for experimental cardiac surgery: A quantitative histological comparison. Ann Anat 2022; 242:151910. [PMID: 35189268 DOI: 10.1016/j.aanat.2022.151910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is a common cardiac surgery. Manufacturing small-diameter (2-5mm) vascular grafts for CABG is important for patients who lack first-choice autologous arterial, or venous conduits. Ovine and porcine common carotid arteries (CCAs) are used as large animal models for in vivo testing of newly developed tissue-engineered arterial grafts. It is unknown to what extent these models are interchangeable and whether the left and right arteries of the same subjects can be used as experimental controls. Therefore, we compared the microscopic structure of paired left and right ovine and porcine CCAs in the proximodistal direction and compared these animal model samples to samples of human coronary arteries (CAs) and human internal thoracic arteries (ITAs). METHODS We compared the histological composition of whole CCAs of sheep (n=22 animals) with whole porcine CCAs (n=21), segments of human CAs (n=21), and human ITAs (n=21). Using unbiased sampling and stereological methods, we quantified the fractions of elastin, total collagen, type I collagen, type III collagen, smooth muscle actin (SMA) and chondroitin sulfate (CS) A, B, and C. We also quantified the densities and distributions of nuclear profiles, nervi vasorum and vasa vasorum as well as the thickness of the intima-media and total wall thickness. RESULTS The differences between the paired samples of left and right CCAs in sheep were substantially greater than the differences in laterality in porcine CCAs. The right ovine CCAs had a smaller fraction of elastin (p<0.001), greater fraction of SMA (p<0.01), and greater intima-media thickness (p<0.001) than the paired left side CCAs. In pigs, the right CCAs had a greater fraction of elastin (p<0.05) and a greater density of vasa vasorum in the media (p<0.001) than the left-side CCAs. The fractions of elastin and CS decreased and the fraction of SMA increased in the proximodistal direction in both the ovine (p<0.001) and porcine (p<0.001) CCAs. Ovine CCAs had a muscular phenotype along their entire length, but porcine CCAs were elastic-type arteries in the proximal segments but muscular type arteries in middle and distal segments. The CCAs of both animals differed from the human CAs and ITAs in most parameters, but the ovine CCAs had a comparable fraction of elastin and CS to human ITAs. CONCLUSIONS From a histological point of view, ovine and porcine CCAs were not equivalent in most quantitative parameters to human CAs and ITAs. Left and right ovine CCAs did not have the same histological composition, which is limiting for their mutual equivalence as sham-operated controls in experiments. These differences should be taken into account when designing and interpreting experiments using these models in cardiac surgery. The complete morphometric data obtained by quantitative evaluation of arterial segments were provided to facilitate the power analysis necessary for justification of the minimum number of samples when planning further experiments. The middle or distal segments of ovine and porcine CCAs remain the most realistic and the best characterized large animal models for testing artificial arterial CABG conduits.
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Affiliation(s)
- Martina Grajciarová
- Department of Histology and Embryology and Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Karlovarska 48, 301 66 Pilsen, Czech Republic
| | - Daniel Turek
- First Faculty of Medicine, Charles University, Katerinska 32, 121 08 Prague 2, Czech Republic; Department of Cardiac Surgery, Institute for Clinical and Experimental Medicine, Videnska 1958/9, 140 21 Prague, Czech Republic
| | - Anna Malečková
- Department of Histology and Embryology and Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Karlovarska 48, 301 66 Pilsen, Czech Republic
| | - Richard Pálek
- Department of Surgery and Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Husova 3, 306 05 Pilsen, Czech Republic
| | - Václav Liška
- Department of Surgery and Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Husova 3, 306 05 Pilsen, Czech Republic
| | - Petr Tomášek
- Department of Histology and Embryology and Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Karlovarska 48, 301 66 Pilsen, Czech Republic; Department of Forensic Medicine, Second Faculty of Medicine, Charles University and Na Bulovce Hospital, Budinova 2, 180 81 Prague, Czech Republic
| | - Milena Králičková
- Department of Histology and Embryology and Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Karlovarska 48, 301 66 Pilsen, Czech Republic
| | - Zbyněk Tonar
- Department of Histology and Embryology and Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Karlovarska 48, 301 66 Pilsen, Czech Republic.
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A Comparative Study of an Anti-Thrombotic Small-Diameter Vascular Graft with Commercially Available e-PTFE Graft in a Porcine Carotid Model. Tissue Eng Regen Med 2022; 19:537-551. [PMID: 35167044 PMCID: PMC9130378 DOI: 10.1007/s13770-021-00422-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 12/11/2022] Open
Abstract
Background: We have designed a reinforced drug-loaded vascular graft composed of polycaprolactone (PCL) and polydioxanone (PDO) via a combination of electrospinning/3D printing approaches. To evaluate its potential for clinical application, we compared the in vivo blood compatibility and performance of PCL/PDO + 10%DY grafts doped with an antithrombotic drug (dipyridamole) with a commercial expanded polytetrafluoroethylene (e-PTFE) graft in a porcine model. Methods: A total of 10 pigs (weight: 25–35 kg) were used in this study. We made a new 5-mm graft with PCL/PDO composite nanofiber via the electrospinning technique. We simultaneously implanted a commercially available e-PTFE graft (n = 5) and our PCL/PDO + 10%DY graft (n = 5) into the carotid arteries of the pigs. No anticoagulant/antiplatelet agent was administered during the follow-up period, and ultrasonography was performed weekly to confirm the patency of the two grafts in vivo. Four weeks later, we explanted and compared the performance of the two grafts by histological analysis and scanning electron microscopy (SEM). Results: No complications, such as sweating on the graft or significant bleeding from the needle hole site, were seen in the PCL/PDO + 10%DY graft immediately after implantation. Serial ultrasonographic examination and immunohistochemical analysis demonstrated that PCL/PDO + 10%DY grafts showed normal physiological blood flow and minimal lumen reduction, and pulsed synchronously with the native artery at 4 weeks after implantation. However, all e-PTFE grafts occluded within the study period. The luminal surface of the PCL/PDO + 10%DY graft in the transitional zone was fully covered with endothelial cells as observed by SEM. Conclusion: The PCL/PDO + 10%DY graft was well tolerated, and no adverse tissue reaction was observed in porcine carotid models during the short-term follow-up. Colonization of the graft by host endothelial and smooth muscle cells coupled with substantial extracellular matrix production marked the regenerative capability. Thus, this material may be an ideal substitute for vascular reconstruction and bypass surgeries. Long-term observations will be necessary to determine the anti-thrombotic and remodeling potential of this device. Supplementary Information The online version contains supplementary material available at 10.1007/s13770-021-00422-4.
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Wolfe JT, Shradhanjali A, Tefft BJ. Strategies for improving endothelial cell adhesion to blood-contacting medical devices. TISSUE ENGINEERING PART B-REVIEWS 2021; 28:1067-1092. [PMID: 34693761 DOI: 10.1089/ten.teb.2021.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The endothelium is a critical mediator of homeostasis on blood-contacting surfaces in the body, serving as a selective barrier to regulate processes such as clotting, immune cell adhesion, and cellular response to fluid shear stress. Implantable cardiovascular devices including stents, vascular grafts, heart valves, and left ventricular assist devices are in direct contact with circulating blood and carry a high risk for platelet activation and thrombosis without a stable endothelial cell (EC) monolayer. Development of a healthy endothelium on the blood-contacting surface of these devices would help ameliorate risks associated with thrombus formation and eliminate the need for long-term anti-platelet or anti-coagulation therapy. Although ECs have been seeded onto or recruited to these blood-contacting surfaces, most ECs are lost upon exposure to shear stress due to circulating blood. Many investigators have attempted to generate a stable EC monolayer by improving EC adhesion using surface modifications, material coatings, nanofiber topology, and modifications to the cells. Despite some success with enhanced EC retention in vitro and in animal models, no studies to date have proven efficacious for routinely creating a stable endothelium in the clinical setting. This review summarizes past and present techniques directed at improving the adhesion of ECs to blood-contacting devices.
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Affiliation(s)
- Jayne Taylor Wolfe
- Medical College of Wisconsin, 5506, Biomedical Engineering, 8701 Watertown Plank Rd, Milwaukee, Wisconsin, United States, 53226-0509;
| | - Akankshya Shradhanjali
- Medical College of Wisconsin, 5506, Biomedical Engineering, Milwaukee, Wisconsin, United States;
| | - Brandon J Tefft
- Medical College of Wisconsin, 5506, Biomedical Engineering, Milwaukee, Wisconsin, United States;
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Roina Y, Auber F, Hocquet D, Herlem G. ePTFE-based biomedical devices: An overview of surgical efficiency. J Biomed Mater Res B Appl Biomater 2021; 110:302-320. [PMID: 34520627 DOI: 10.1002/jbm.b.34928] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/26/2021] [Accepted: 08/01/2021] [Indexed: 12/19/2022]
Abstract
Polytetrafluoroethylene (PTFE) is a ubiquitous material used for implants and medical devices in general because of its high biocompatibility and inertness: blood vessel, heart, table jawbone, nose, eyes, or abdominal wall can benefit from its properties in case of disease or injury. Its expanded version, ePTFE is an improved version of PTFE with better mechanical properties, which extends its medical applications. A material as frequently used as ePTFE with these exceptional properties deserves a review of its main uses, developments, and possibility of improvements. In this systematic review, we examined clinical trials related to ePTFE-based medical devices from the literature. Then, we excluded all trials using ePTFE as a control to test other devices. ePTFE-coated stents, hemodialysis and bypass grafts, guided bone and tissue regeneration membranes, hernia and heart repair and other devices are reviewed. The rates of success using these devices and their efficiency compared to other materials used for the same purposes are reported. ePTFE appears to be more or just as efficient compared to them. Some success rates remain low, suggesting the need of improvement ePTFE for medical applications.
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Affiliation(s)
- Yaëlle Roina
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
| | - Frédéric Auber
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
| | - Didier Hocquet
- Hygiène Hospitalière, UMR CNRS 6249, Université de Bourgogne Franche-Comté, Besançon, France
| | - Guillaume Herlem
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
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Hyaluronan promotes the regeneration of vascular smooth muscle with potent contractile function in rapidly biodegradable vascular grafts. Biomaterials 2020; 257:120226. [DOI: 10.1016/j.biomaterials.2020.120226] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/30/2020] [Accepted: 07/04/2020] [Indexed: 12/15/2022]
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Badv M, Bayat F, Weitz JI, Didar TF. Single and multi-functional coating strategies for enhancing the biocompatibility and tissue integration of blood-contacting medical implants. Biomaterials 2020; 258:120291. [PMID: 32798745 DOI: 10.1016/j.biomaterials.2020.120291] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/27/2020] [Accepted: 08/01/2020] [Indexed: 12/27/2022]
Abstract
Device-associated clot formation and poor tissue integration are ongoing problems with permanent and temporary implantable medical devices. These complications lead to increased rates of mortality and morbidity and impose a burden on healthcare systems. In this review, we outline the current approaches for developing single and multi-functional surface coating techniques that aim to circumvent the limitations associated with existing blood-contacting medical devices. We focus on surface coatings that possess dual hemocompatibility and biofunctionality features and discuss their advantages and shortcomings to providing a biocompatible and biodynamic interface between the medical implant and blood. Lastly, we outline the newly developed surface modification techniques that use lubricant-infused coatings and discuss their unique potential and limitations in mitigating medical device-associated complications.
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Affiliation(s)
- Maryam Badv
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada; Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Fereshteh Bayat
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada; Thrombosis & Atherosclerosis Research Institute (TaARI), Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Tohid F Didar
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada; Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada; Institute for Infectious Disease Research (IIDR), McMaster University, Hamilton, Ontario, Canada.
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12
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Sefton MV, Gorbet MB. Nonthrombogenic Treatments and Strategies. Biomater Sci 2020. [DOI: 10.1016/b978-0-12-816137-1.00035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Wang B, Feng C, Dang J, Niu L, Shen C, Yang X, Zhang T, Zhang X. Anti-Adhesive, Platelet Gathering Effects of c-RGD Modified Poly(p-dioxanone-co-l-Phe) Electrospun Membrane and Its Comprehensive Application in Intestinal Anastomosis. Macromol Biosci 2019; 20:e1900344. [PMID: 31854121 DOI: 10.1002/mabi.201900344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/05/2019] [Indexed: 11/06/2022]
Abstract
Intestinal resection and anastomosis are performed in over a million people with various bowel diseases annually. Excessive fibrosis and anastomotic site leakage are the main complications of anastomosis surgery, despite great improvements in operative technique and equipment in recent years. In this study, cRGD modified poly(p-dioxanone-co-l-Phe) (PDPA) membranes are designed and applied in intestinal anastomosis to simultaneously solve the two aforementioned complications. cRGD is modified onto PDPA membranes through both physical absorption and π-π accumulation between d-Phe of cRGD and l-Phe of PDPA. Although cRGD modification enhanced the biocompatibility of PDPA membranes, cRGD modified PDPA membrane suppresses fibroblast proliferation both in vitro and in vivo as a result of degradation and subsequent release of fibroblast suppressive l-Phe from PDPA. Meanwhile, platelets are entrapped by cRGD modified PDPA membranes through the specific binding of cRGD and platelet GPIIbIIIa . cRGD modified PDPA membranes are applied in rat intestinal anastomosis, and both adhesion and stenosis are successfully prevented at anastomotic sites. At the same time, bursting pressure, which represents healing intensity at anastomotic sites, is promoted. The gathering and activation of platelets on PDPA membranes induce secretion of autologous PDGF and VEGF to facilitate angiogenesis and subsequent healing of anastomotic sites.
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Affiliation(s)
- Bing Wang
- Sichuan Key Laboratory of Medical Imaging & Department of Chemistry, School of Preclinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Chengmin Feng
- Department of Clinical Medicine, North Sichuan Medical College & Department of Otolaryngology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China
| | - Jiafeng Dang
- Department of Clinical Medicine, North Sichuan Medical College & Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China
| | - Lijing Niu
- Department of Pathology, School of Preclinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Chengyi Shen
- Sichuan Key Laboratory of Medical Imaging & Institute of Morphological Research, North Sichuan Medical College, Nanchong, 637000, China
| | - Xiaomei Yang
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Ting Zhang
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Xiaoming Zhang
- Sichuan Key Laboratory of Medical Imaging & Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China
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14
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Badv M, Alonso-Cantu C, Shakeri A, Hosseinidoust Z, Weitz JI, Didar TF. Biofunctional Lubricant-Infused Vascular Grafts Functionalized with Silanized Bio-Inks Suppress Thrombin Generation and Promote Endothelialization. ACS Biomater Sci Eng 2019; 5:6485-6496. [DOI: 10.1021/acsbiomaterials.9b01062] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | | | | | | | - Jeffrey I. Weitz
- Thrombosis & Atherosclerosis Research Institute (TaARI), 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
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15
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Clauder F, Czerniak AS, Friebe S, Mayr SG, Scheinert D, Beck-Sickinger AG. Endothelialization of Titanium Surfaces by Bioinspired Cell Adhesion Peptide Coatings. Bioconjug Chem 2019; 30:2664-2674. [DOI: 10.1021/acs.bioconjchem.9b00573] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Franziska Clauder
- Institute of Biochemistry, Faculty of Life Sciences, Leipzig University, Brüderstrasse 34, 04103 Leipzig, Germany
| | - Anne Sophie Czerniak
- Institute of Biochemistry, Faculty of Life Sciences, Leipzig University, Brüderstrasse 34, 04103 Leipzig, Germany
| | - Sabrina Friebe
- Leibniz-Institute of Surface Engineering (IOM), Permoserstrasse 15, 04318 Leipzig, Germany
| | - Stefan G. Mayr
- Leibniz-Institute of Surface Engineering (IOM), Permoserstrasse 15, 04318 Leipzig, Germany
| | - Dierk Scheinert
- Department of Angiology, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Annette G. Beck-Sickinger
- Institute of Biochemistry, Faculty of Life Sciences, Leipzig University, Brüderstrasse 34, 04103 Leipzig, Germany
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16
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Accelerated endothelialization and suppressed thrombus formation of acellular vascular grafts by modifying with neointima-inducing peptide: A time-dependent analysis of graft patency in rat-abdominal transplantation model. Colloids Surf B Biointerfaces 2019; 181:806-813. [DOI: 10.1016/j.colsurfb.2019.06.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 01/07/2023]
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17
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Biocompatibility of Small-Diameter Vascular Grafts in Different Modes of RGD Modification. Polymers (Basel) 2019; 11:polym11010174. [PMID: 30960158 PMCID: PMC6401695 DOI: 10.3390/polym11010174] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 12/22/2022] Open
Abstract
Modification with Arg-Gly-Asp (RGD) peptides is a promising approach to improve biocompatibility of small-calibre vascular grafts but it is unknown how different RGD sequence composition impacts graft performance. Here we manufactured 1.5 mm poly(3-hydroxybutyrate-co-3-hydroxyvalerate)/poly(ε-caprolactone) grafts modified by distinct linear or cyclic RGD peptides immobilized by short or long amine linker arms. Modified vascular prostheses were tested in vitro to assess their mechanical properties, hemocompatibility, thrombogenicity and endothelialisation. We also implanted these grafts into rat abdominal aortas with the following histological examination at 1 and 3 months to evaluate their primary patency, cellular composition and detect possible calcification. Our results demonstrated that all modes of RGD modification reduce ultimate tensile strength of the grafts. Modification of prostheses does not cause haemolysis upon the contact with modified grafts, yet all the RGD-treated grafts display a tendency to promote platelet aggregation in comparison with unmodified counterparts. In vivo findings identify that cyclic Arg-Gly-Asp-Phe-Lys peptide in combination with trioxa-1,13-tridecanediamine linker group substantially improve graft biocompatibility. To conclude, here we for the first time compared synthetic small-diameter vascular prostheses with different modes of RGD modification. We suggest our graft modification regimen as enhancing graft performance and thus recommend it for future use in tissue engineering.
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Iijima M, Aubin H, Steinbrink M, Schiffer F, Assmann A, Weisel RD, Matsui Y, Li RK, Lichtenberg A, Akhyari P. Bioactive coating of decellularized vascular grafts with a temperature-sensitive VEGF-conjugated hydrogel accelerates autologous endothelialization in vivo. J Tissue Eng Regen Med 2017; 12:e513-e522. [DOI: 10.1002/term.2321] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/06/2016] [Accepted: 09/26/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Makoto Iijima
- Department of Cardiovascular Surgery and Research Group for Experimental Surgery; Heinrich Heine University, Medical Faculty; Düsseldorf Germany
| | - Hug Aubin
- Department of Cardiovascular Surgery and Research Group for Experimental Surgery; Heinrich Heine University, Medical Faculty; Düsseldorf Germany
| | - Meike Steinbrink
- Department of Cardiovascular Surgery and Research Group for Experimental Surgery; Heinrich Heine University, Medical Faculty; Düsseldorf Germany
| | - Franziska Schiffer
- Department of Cardiovascular Surgery and Research Group for Experimental Surgery; Heinrich Heine University, Medical Faculty; Düsseldorf Germany
| | - Alexander Assmann
- Department of Cardiovascular Surgery and Research Group for Experimental Surgery; Heinrich Heine University, Medical Faculty; Düsseldorf Germany
| | - Richard D. Weisel
- Toronto General Research Institute, University Health Network and Department of Surgery, Division of Cardiovascular Surgery; University of Toronto; Toronto Ontario Canada
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery; Hokkaido University, Graduate school of Medicine; Sapporo Japan
| | - Ren-Ke Li
- Toronto General Research Institute, University Health Network and Department of Surgery, Division of Cardiovascular Surgery; University of Toronto; Toronto Ontario Canada
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery and Research Group for Experimental Surgery; Heinrich Heine University, Medical Faculty; Düsseldorf Germany
| | - Payam Akhyari
- Department of Cardiovascular Surgery and Research Group for Experimental Surgery; Heinrich Heine University, Medical Faculty; Düsseldorf Germany
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19
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Aubin H, Mas-Moruno C, Iijima M, Schütterle N, Steinbrink M, Assmann A, Gil FJ, Lichtenberg A, Pegueroles M, Akhyari P. Customized Interface Biofunctionalization of Decellularized Extracellular Matrix: Toward Enhanced Endothelialization. Tissue Eng Part C Methods 2016; 22:496-508. [PMID: 27018545 PMCID: PMC4870611 DOI: 10.1089/ten.tec.2015.0556] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/15/2016] [Indexed: 11/12/2022] Open
Abstract
Interface biofunctionalization strategies try to enhance and control the interaction between implants and host organism. Decellularized extracellular matrix (dECM) is widely used as a platform for bioengineering of medical implants, having shown its suitability in a variety of preclinical as well as clinical models. In this study, specifically designed, custom-made synthetic peptides were used to functionalize dECM with different cell adhesive sequences (RGD, REDV, and YIGSR). Effects on in vitro endothelial cell adhesion and in vivo endothelialization were evaluated in standardized models using decellularized ovine pulmonary heart valve cusps (dPVCs) and decellularized aortic grafts (dAoGs), respectively. Contact angle measurements and fluorescent labeling of custom-made peptides showed successful functionalization of dPVCs and dAoGs. The functionalization of dPVCs with a combination of bioactive sequences significantly increased in vitro human umbilical vein endothelial cell adhesion compared to nonfunctionalized controls. In a functional rodent aortic transplantation model, fluorescent-labeled peptides on dAoGs were persistent up to 10 days in vivo under exposure to systemic circulation. Although there was a trend toward enhanced in vivo endothelialization of functionalized grafts compared to nonfunctionalized controls, there was no statistical significance and a large biological variability in both groups. Despite failing to show a clear biological effect in the used in vivo model system, our initial findings do suggest that endothelialization onto dECM may be modulated by customized interface biofunctionalization using the presented method. Since bioactive sequences within the dECM-synthetic peptide platform are easily interchangeable and combinable, further control of host cell proliferation, function, and differentiation seems to be feasible, possibly paving the way to a new generation of multifunctional dECM scaffolds for regenerative medicine.
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Affiliation(s)
- Hug Aubin
- Department of Cardiovascular Surgery, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
- Research Group for Experimental Surgery, Department of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Carlos Mas-Moruno
- Biomaterials, Biomechanics and Tissue Engineering Group, Department of Materials Science and Metallurgical Engineering, Technical University of Catalonia (UPC), Barcelona, Spain
- Center for Research in NanoEngineering (CRNE), Technical University of Catalonia (UPC), Barcelona, Spain
| | - Makoto Iijima
- Research Group for Experimental Surgery, Department of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Nicolas Schütterle
- Research Group for Experimental Surgery, Department of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Meike Steinbrink
- Research Group for Experimental Surgery, Department of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexander Assmann
- Department of Cardiovascular Surgery, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
- Research Group for Experimental Surgery, Department of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Francesc Javier Gil
- Biomaterials, Biomechanics and Tissue Engineering Group, Department of Materials Science and Metallurgical Engineering, Technical University of Catalonia (UPC), Barcelona, Spain
- Center for Research in NanoEngineering (CRNE), Technical University of Catalonia (UPC), Barcelona, Spain
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
- Research Group for Experimental Surgery, Department of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Marta Pegueroles
- Biomaterials, Biomechanics and Tissue Engineering Group, Department of Materials Science and Metallurgical Engineering, Technical University of Catalonia (UPC), Barcelona, Spain
- Center for Research in NanoEngineering (CRNE), Technical University of Catalonia (UPC), Barcelona, Spain
| | - Payam Akhyari
- Department of Cardiovascular Surgery, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
- Research Group for Experimental Surgery, Department of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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20
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Bastijanic JM, Kligman FL, Marchant RE, Kottke-Marchant K. Dual biofunctional polymer modifications to address endothelialization and smooth muscle cell integration of ePTFE vascular grafts. J Biomed Mater Res A 2015; 104:71-81. [DOI: 10.1002/jbm.a.35541] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 07/10/2015] [Accepted: 07/14/2015] [Indexed: 01/02/2023]
Affiliation(s)
| | - Faina L. Kligman
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic; Cleveland Ohio
| | - Roger E. Marchant
- Department of Biomedical Engineering; Case Western Reserve University; Cleveland Ohio
| | - Kandice Kottke-Marchant
- Department of Biomedical Engineering; Case Western Reserve University; Cleveland Ohio
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic; Cleveland Ohio
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