Dual drug-eluting stents coated with multilayers of hydrophobic heparin and sirolimus

Pharmacological prevention of intimal hyperplasia: A state-of-the-art review

Intimal hyperplasia (IH) occurs in a considerable number of cases of blood vessel reconstruction by stenting or balloon angioplasty, venous bypass grafting, and arteriovenous dialysis accesses. It is triggered by endothelial injury during the vascular intervention and leads to vessel restenosis with life-threatening consequences for patients. To date, the drugs used for IH prevention in clinics-paclitaxel and rapalog drugs-have been focusing primarily on the vascular smooth muscle cell (VSMC) proliferation pathway of IH development. Limitations, such as endothelial toxicity and inappropriate drug administration timing, have spurred the search for new and efficient pharmacological approaches to control IH. In this state-of-the-art review, we present the pathways of IH development, focusing on the key events and actors involved in IH. Subsequently, we discuss different drugs and drug combinations interfering with these pathways based on their effect on peripheral circulation IH models in animal studies, or on clinical reports. The reports were obtained through an extensive search of peer-reviewed publications in Pubmed, Embase, and Google Scholar, with search equations composed based on five concepts around IH and their various combinations. To improve vascular intervention outcomes, rethinking of conventional therapeutic approaches to IH prevention is needed. Exploring local application of drugs and drug combinations acting on different pathophysiological pathways of IH development has the potential to provide effective and safe restenosis prevention.

The Use of Bioactive Polymers for Intervention and Tissue Engineering: The New Frontier for Cardiovascular Therapy

Coronary heart disease remains one of the leading causes of death in most countries. Healthcare improvements have seen a shift in the presentation of disease with a reducing number of ST-segment elevation myocardial infarctions (STEMIs), largely due to earlier reperfusion strategies such as percutaneous coronary intervention (PCI). Stents have revolutionized the care of these patients, but the long-term effects of these devices have been brought to the fore. The conceptual and technologic evolution of these devices from bare-metal stents led to the creation and wide application of drug-eluting stents; further research introduced the idea of polymer-based resorbable stents. We look at the evolution of stents and the multiple advantages and disadvantages offered by each of the different polymers used to make stents in order to identify what the stent of the future may consist of whilst highlighting properties that are beneficial to the patient alongside the role of the surgeon, the cardiologist, engineers, chemists, and biophysicists in creating the ideal stent.

Histopathologic response after hydrophilic polyethylene glycol-coating stent and hydrophobic octadecylthiol-coating stent implantations in porcine coronary restenosis model

Device-related problems of drug-eluting stents, including stent thrombosis related to antiproliferative drugs and polymers, can cause adverse events such as inflammation and neointimal hyperplasia. Stent surface modification, wherein the drug and polymer are not required, may overcome these problems. We developed hydrophilic polyethylene glycol (PEG)-coating and hydrophobic octadecylthiol (ODT)-coating stents without a drug and polymer and evaluated their histopathologic response in a porcine coronary restenosis model. PEG-coating stents (n = 12), bare-metal stents (BMS) (n = 12), and ODT-coating stents (n = 10) were implanted with oversizing in 34 porcine coronary arteries. Four weeks later, the histopathologic response, arterial injury, inflammation, and fibrin scores were analyzed. A p value < 0.05 was considered statistically significant. There were significant differences in the internal elastic lamina area, lumen area, neointimal area, percent area of stenosis, arterial injury score, inflammation score, and fibrin score among the groups. Compared to the BMS or ODT-coating stent group, the PEG-coating stent group had significantly increased internal elastic lamina and lumen area (all p < 0.001) and decreased neointimal area and percent area of stenosis (BMS: p = 0.03 and p < 0.001, respectively; ODT-coating: p = 0.013 and p < 0.001, respectively). Similarly, the PEG-coating group showed significantly lower inflammation and fibrin scores than the BMS or ODT-coating groups (BMS: p = 0.013 and p = 0.007, respectively; ODT-coating: p = 0.014 and p = 0.008, respectively). In conclusion, hydrophilic PEG-coating stent implantation was associated with lower inflammatory response, decreased fibrin deposition, and reduced neointimal hyperplasia than BMS or hydrophobic ODT-coating stent implantation in the porcine coronary restenosis model.

Coronary Stents Decorated by Heparin/NONOate Nanoparticles for Anticoagulant and Endothelialized Effects

In the treatment of coronary artery disease (CAD), the use of stent implantation often leads to clinical complications such as restenosis, delayed endothelial healing, and thrombosis. Here, we develop a double drug sustained-release coating for the stent surface by grafting heparin/NONOate nanoparticles (Hep/NONOates). The Hep/NONOates and surface modification of the stent were characterized by X-ray photoelectron spectroscopy, attenuated total reflection Fourier-transform infrared spectroscopy, static water contact angle, and scanning electron microscopy (SEM), and the release behaviors of the anticoagulant, heparin (Hep) and the bioactive molecule, nitric oxide (NO) were studied. Furthermore, the blood compatibility and cytotoxicity of the modified stent were evaluated by whole blood adhesion and platelet adhesion tests, hemolysis assay, morphological changes of red blood cells, plasma recalcification time assay, in vitro coagulation time tests, and MTT assay. Finally, the results of a rabbit carotid artery stent implantation experiment showed that the double drug sustained-release coating for the stent can accelerate regeneration of endothelial cells and keep good anticoagulant activity. This study can provide new design ideas based on nanotechnology for improving the safety and effectiveness of drug-eluting stents.

Layer-by-Layer Deposition of Hyaluronan and Quercetin-Loaded Chitosan Nanoparticles onto Titanium for Improving Blood Compatibility

Surface modification is an effective way to improve the hemocompatibility of biomaterials. Quercetin has significant anticoagulation and antithrombotic effects, and thus it is a promising candidate agent for the surface modification of blood-contacting materials. In this study, quercetin was successfully encapsulated in tripolyphosphate–chitosan nanoparticles (TCs) based on the ionic gelation of chitosan with tripolyphosphate (TPP) anions. Then, hyaluronan acid (HA)/quercetin-loaded TPP–chitosan nanoparticle (QTCs) films, in addition to HA/TCs films, were prepared separately using an electrostatic layer-by-layer self-assembly technique. The encapsulation of quercetin in the chitosan nanoparticles was confirmed by UV spectra. The quercetin-loaded multilayer coatings were also successfully self-assembled, as confirmed by the UV spectra and contact angle measurements. Platelet adhesion experiments were carried out with platelet-enriched plasma so as to evaluate the blood compatibility of the different samples. There were many platelets on the surfaces of the glass and HA/TC-coated titanium, which were partially activated but not aggregated. Meanwhile, many more platelets were observed on the uncoated titanium surfaces, most of which developed pseudopodia. By contrast, the platelet adhesion and activation were reduced remarkably on the surface of the HA/QTC-coated titanium. These results showed that the multilayer coatings containing quercetin could act as potential biomaterials to improve the anticoagulation performance of blood-contacting materials.

Ta ion implanted nanoridge-platform for enhanced vascular responses

Bare metal stents are commonly used in interventional cardiology; they provide successful treatment because of their excellent mechanical properties, expandability ratios, and flexibility. However, their insufficient vascular affinity can induce the development of neointimal hyperplasia following arterial injury and subsequent smooth muscle cell overgrowth in the lumen of a stented vessel. Nanoengineering of the bare metal stent surface is a valuable strategy for eliciting favorable vascular responses. In this study, we introduce a target-ion-induced plasma sputtering (TIPS) technique to fabricate a platform with a favorable endothelial environment. This technique enables the simple single-step production of a Ta-implanted nanoridged surface on a stent with a complex 3D geometry that shows a clear tendency to become oriented parallel to the direction of blood flow. Moreover, the nanoridges developed show good structural integrity and mechanical stability, resulting in apparently stable morphologies under high strain rates. In vitro cellular responses to the Co-Cr, such as endothelialization, platelet activation, and blood coagulation, are considerably altered after TIPS treatment; endothelium formation is rapid and surface thrombogenicity is low. An in vivo rabbit iliac artery model is used to confirm that the nanoridged surface facilitates rapid re-endothelialization and limits the formation of neointima compared to the bare stent. These results indicate that the Ta ion implanted nanoridge platform fabricated using the TIPS technique has immense potential as a solution for in-stent restenosis and ensuring the long-term patency of bare metal stents.

Evaluation of the suitability of a fluidized bed process for the coating of drug-eluting stents

Drug-eluting stents are often coated using single-stent coating techniques. In pharmaceutical industry, single-tablet coating is unthinkable. Instead large batches of tablets are coated in fluidized bed apparatuses or pan coaters. Therefore, it was the aim of this work to evaluate whether stents can be coated using a fluidized bed process. For this purpose stents were coated with the model fluorescent drug triamterene embedded in ammonium methacrylate copolymer. Different stent lengths as well as different coating yields were assessed and also a drug-free topcoat was evaluated. The coated stents were analysed regarded coating layer mass, drug content, surface structure, coating thickness and drug release. Furthermore, coating yield and stent defect rate were examined. Except for one stent configuration good results were obtained without optimization of process parameters which indicates the suitability of the method to coat large amounts of stents simultaneously in principle. Drug release was tuneable over a wide range of time spans and a wide range of drug loadings was produced. Further work will be necessary to transform the results of this study from a model stent to a clinically relevant product.

Multiple Drug Delivery from Mesoporous Coating Realizing Combination Therapy for Bare Metal Stents

The simultaneous loading of multifunctional drugs has been regarded as one of the major challenges in the drug delivery system. Herein, a mesoporous silica coating was constructed on a bare metal stent surface by an evaporation-induced self-assembly method, in which both hydrophilic and hydrophobic drugs (heparin and rapamycin) were encapsulated by a one-pot method for the first time, and the release behaviors of these drugs were studied. The releasing mechanisms of these drugs were investigated in detail. Rapid release of heparin can achieve anticoagulation and endothelialization, whereas slow release of rapamycin can realize antiproliferative therapy for long term. In vitro hemocompatibility and promotion for proliferation of vein endothelial cells and the inhibition of smooth muscle cells were conducted. In vivo stent implantation results verify that the mesoporous silica coating with both heparin and rapamycin can successfully accelerate the endothelialization process and realize the antiproliferative therapy for as long as 3 months. These results indicate that this multifunctional mesoporous coating containing both hydrophilic and hydrophobic drugs might be a promising stent coating in the future.

Targeted Delivery of Bioactive Molecules for Vascular Intervention and Tissue Engineering

Cardiovascular diseases are the leading cause of death in the United States. Treatment often requires surgical interventions to re-open occluded vessels, bypass severe occlusions, or stabilize aneurysms. Despite the short-term success of such interventions, many ultimately fail due to thrombosis or restenosis (following stent placement), or incomplete healing (such as after aneurysm coil placement). Bioactive molecules capable of modulating host tissue responses and preventing these complications have been identified, but systemic delivery is often harmful or ineffective. This review discusses the use of localized bioactive molecule delivery methods to enhance the long-term success of vascular interventions, such as drug-eluting stents and aneurysm coils, as well as nanoparticles for targeted molecule delivery. Vascular grafts in particular have poor patency in small diameter, high flow applications, such as coronary artery bypass grafting (CABG). Grafts fabricated from a variety of approaches may benefit from bioactive molecule incorporation to improve patency. Tissue engineering is an especially promising approach for vascular graft fabrication that may be conducive to incorporation of drugs or growth factors. Overall, localized and targeted delivery of bioactive molecules has shown promise for improving the outcomes of vascular interventions, with technologies such as drug-eluting stents showing excellent clinical success. However, many targeted vascular drug delivery systems have yet to reach the clinic. There is still a need to better optimize bioactive molecule release kinetics and identify synergistic biomolecule combinations before the clinical impact of these technologies can be realized.

Hemocompatibility and anti-fouling behavior of multilayer biopolymers immobilized on gold-thiolized drug-eluting cardiovascular stents

To solve the thrombosis and restenosis problem in cardiovascular stent implantation for cardiovascular artery disease, chondroitin 6-sulfate (ChS) with heparin (HEP) have been used as drug carrier layers and alternatively covalently bonded on gold (Au)-dimercaptosuccinic acid (DMSA)-thiolized cardiovascular metallic (SUS316 L stainless steel, SS) stents. Sirolimus, a model drug, was encapsulated in the ChS-HEP alternative layers. The behavior of the drug in releasing and suppressing the growth of smooth-muscle cells (SMCs) was evaluated with 5-layer CHS-HEP coating on the SS stents. Moreover, hemocompatibility of blood clotting time and platelet adhesion was performed. The results showed that the 5-layer ChS-HEP-modified SS stents displayed the greatest hemocompatibility, showing prolonged blood clotting time of the activated partial thrombin time (> 500 s) and less platelet adhesion to reduce thrombosis. Furthermore, sirolimus can be released continuously for more than 40 days with the 5-layer ChS-HEP coating and is beneficial for inhibiting the growth of SMCs; however, it does not affect the proliferation of endothelial cells, which can avoid restenosis formation. Therefore, the multilayers of ChS-HEP grafted onto the Au-DMSA-cardiovascular SS stents provide high potential for use as drug eluting stents.

Advancements and Challenges in Multidomain Multicargo Delivery Vehicles

Reparative and regenerative processes are well-orchestrated temporal and spatial events that are governed by multiple cells, molecules, signaling pathways, and interactions thereof. Yet again, currently available implantable devices fail largely to recapitulate nature's complexity and sophistication in this regard. Herein, success stories and challenges in the field of layer-by-layer, composite, self-assembly, and core-shell technologies are discussed for the development of multidomain/multicargo delivery vehicles.

Coadministration of Oligomeric Hyaluronic Acid-Modified Liposomes with Tumor-Penetrating Peptide-iRGD Enhances the Antitumor Efficacy of Doxorubicin against Melanoma

A safe and efficient tumor-targeting strategy based on oligomeric hyaluronic acid (HA) modification and coadministration of tumor-penetrating peptide-iRGD was successfully developed. In this study, common liposomes (cLip) were modified by oligomeric HA to obtain HA-Lip. After injection into rats, HA-Lip showed good stealth in the bloodstream and lower liver distribution compared with cLip. Moreover, our HA-Lip could be internalized into B16F10 cells (CD44-overexpressing tumor cells) through HA-CD44 interaction. After systemic administration to B16F10 melanoma-bearing mice, HA-Lip showed an increased distribution in tumor due to the prolonged blood circulation time and the enhanced penetration and retention effect. When coadministered with iRGD, the tumor penetration of HA-Lip was significantly enhanced, which could promote HA-Lip internalization by tumors cells located in deep tumor regions through receptor-mediated endocytosis. Furthermore, doxorubicin (DOX)-loaded HA-Lip coadministering with iRGD showed much better antitumor effect compared to DOX-loaded cLip and DOX-loaded cLip in combination with iRGD. In systemic toxicity test, DOX-loaded HA-Lip could significantly decrease the cardiotoxicity and myelosuppression of DOX. Taken together, our results demonstrated that coadministration of oligomeric HA-modified liposomes with iRGD could be a promising treatment strategy for targeted therapy of melanoma.

Fabrication and characteristics of dual functionalized vascular stent by spatio-temporal coating

Stent implantation with balloon angioplasty is a widely used treatment for coronary artery diseases. Stents have been developed from bare metal stent (BMS) to advanced forms such as drug-eluting stent (DES). However, modern DES still causes thrombosis and/or in-stent restenosis as long-term outcomes. For effective prevention of these problems, we fabricated a dual functionalized stent using spatio-temporal coating, which has two different surfaces, as a novel type of DES. Hyaluronic acid conjugated with dopamine (HA-DA) was applied to a bare cobalt-chromium (CC) stent prior to abluminal coating of sirolimus (SRL)-in-polymer such as poly(d,l-lactide). The SRL-in-polymer (P+S) coated on the abluminal surface of the HA-DA modified stent showed highly stable coating layer and prevented the crack formation after ballooning. In the blood- and cyto-compatibility tests, HA-DA coating displayed suppressive effects on adhesion and activation of platelets and maintained the cell viability and proliferation of human coronary artery endothelial cells even under the existence of SRL. In in vivo study using porcine restenosis model, the neointimal area and inflammation score of the dual functionalized stent with HA-DA and P+S were significantly reduced than those of BMS. It is expected that this novel type of DES can be effectively applied to utilize diverse anti-proliferative drugs and bioactive polymers.

STATEMENT OF SIGNIFICANCE

Stents have been developed from bare metal stent to advanced forms such as drug-eluting stents (DESs). However, even DESs can still cause in-stent restenosis as long-term outcomes. This paper demonstrated a novel DES using spatio-temporal coating by dopamine-mediated hyaluronic acid coating (HA-DA) before asymmetric coating of sirolimus-in-poly(d,l-lactide) (P+S). It showed stable coating surface and prevented crack formation after ballooning. HA-DA coating also had an inhibitive effect on adhesion of platelets and maintained cell viability of endothelial cells even under the existence of sirolimus. Additionally, in vivo neointima area and inflammation score of HA-DA/P+S stent significantly decreased than those of BMS. We expected that this novel type of DES can be effectively applied to introduce diverse anti-proliferative drugs and bioactive molecules.

Coating Techniques and Release Kinetics of Drug-Eluting Stents

Implantation of drug-eluting stents (DESs) via percutaneous coronary intervention is the most popular treatment option to restore blood flow to occluded vasculature. The many devices currently used in clinic and under examination in research laboratories are manufactured using a variety of coating techniques to create the incorporated drug release platforms. These coating techniques offer various benefits including ease of use, expense of equipment, and design variability. This review paper discusses recent novel DES designs utilizing individual or a combination of these coating techniques and their resulting drug release profiles.

Tailoring biomaterial surface properties to modulate host-implant interactions: implication in cardiovascular and bone therapy

Host body response to a foreign medical device plays a critical role in defining its fate post implantation. It is thus important to control host-material interactions by designing innovative implant surfaces. In the recent years, biochemical and topographical features have been explored as main target to produce this new type of bioinert or bioresponsive implants. The review discusses specific biofunctional materials and strategies to achieve a precise control over implant surface properties and presents possible solutions to develop next generation of implants, particularly in the fields of bone and cardiovascular therapy.

Biomolecular strategies to modulate the macrophage response to implanted materials

The material-induced foreign body response is a major challenge for implanted medical devices. This review highlights recent developments in biomimetic approaches to create biomaterials that mitigate the host response to biomaterials. Specifically, we will describe strategies in which biomaterials are decorated with endogenously expressed biomolecules that naturally modulate the function of immune cells. These include molecules that directly bind to and interact with immune cells, as well as molecules that control complement activation or thrombosis and indirectly modulate immune cell function. We provide perspective on how these approaches may impact the design of materials for medical devices and tissue engineering.

Controlling drug delivery from coronary stents: are we aiming for the right targets?

In this review article, the currently employed or explored delivery concepts for local intravascular drug delivery with drug-eluting stents (DES) are discussed with a special emphasis on clinical evidence regarding the desired release profiles. Traditional concepts to control drug release from DES include diffusion through polymers, polymer degradation and erosion as well as dissolution of particulate drug. Published clinical studies do not always reveal fine mechanistic details. The long duration of release favored for DES and the short duration of release favored for drug-eluting balloons require further investigation in experimental studies and clinical trials.

Controlled Slow-Release Drug-Eluting Stents for the Prevention of Coronary Restenosis: Recent Progress and Future Prospects

Drug-eluting stents (DES) have become more widely used by cardiologists than bare metal stents (BMS) because of their better ability to control restenosis. However, recognized negative events, particularly including delayed or incomplete endothelialization and late stent thrombosis, have caused concerns over the long-term safety of DES. Although stent-based drug delivery can facilitate a drug's release directly to the restenosis site, a burst of drug release can seriously affect the pharmacological action and is a major factor accounting for adverse effects. Therefore, the drug release rate has become an important criterion in evaluating DES. The factors affecting the drug release rate include the drug carrier, drug, coating methods, drug storage, elution direction, coating thickness, pore size in the coating, release conditions (release medium, pH value, temperature), and hemodynamics after the stent implantation. A better understanding of how these factors influence drug release is particularly important for the reasonable use of efficient control strategies for drug release. This review summarizes the factors influencing the drug release from DES and presents strategies for enhancing the control of the drug's release, including the stent design, the application of absorbable stents, the development of new polymers, and the application of nanocarriers and improvements in the coating technology. Therefore, this paper provides a reference for the preparation of novel controlled slow-release DES.

Confine Clay in an Alternating Multilayered Structure through Injection Molding: A Simple and Efficient Route to Improve Barrier Performance of Polymeric Materials

Various methods have been devoted to trigger the formation of multilayered structure for wide range of applications. These methods are often complicated with low production efficiency or require complex equipment. Herein, we demonstrate a simple and efficient method for the fabrication of polymeric sheets containing multilayered structure with enhanced barrier property through high speed thin-wall injection molding (HSIM). To achieve this, montmorillonite (MMT) is added into PE first, then blended with PP to fabricate PE-MMT/PP ternary composites. It is demonstrated that alternating multilayer structure could be obtained in the ternary composites because of low interfacial tension and good viscosity match between different polymer components. MMT is selectively dispersed in PE phase with partial exfoliated/partial intercalated microstructure. 2D-WAXD analysis indicates that the clay tactoids in PE-MMT/PP exhibits an uniplanar-axial orientation with their surface parallel to the molded part surface, while the tactoids in binary PE-MMT composites with the same overall MMT contents illustrate less orientation. The enhanced orientation of nanoclay in PE-MMT/PP could be attributed to the confinement of alternating multilayer structure, which prohibits the tumbling and rotation of nanoplatelets. Therefore, the oxygen barrier property of PE-MMT/PP is superior to that of PE-MMT because of increased gas permeation pathway. Comparing with the results obtained for PE based composites in literature, outstanding barrier property performance (45.7% and 58.2% improvement with 1.5 and 2.5 wt % MMT content, respectively) is achieved in current study. Two issues are considered responsible for such improvement: enhanced MMT orientation caused by the confinement in layered structure, and higher local density of MMT in layered structure induced denser assembly. Finally, enhancement in barrier property by confining impermeable filler into alternating multilayer structure through such simple and efficient method could provide a novel route toward high-performance packaging materials and other functional materials require layered structure.

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

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

Surface modification of poly(propylene carbonate) by layer-by-layer assembly and its hemocompatibility

Heparin and lysozyme were used to immobilize onto surface of poly(propylene carbonate) by layer-by-layer assembly to improve hemocompatibility.