The effect of chronic kidney disease on tissue formation of in situ tissue-engineered vascular grafts

Vascular in situ tissue engineering encompasses a single-step approach with a wide adaptive potential and true off-the-shelf availability for vascular grafts. However, a synchronized balance between breakdown of the scaffold material and neo-tissue formation is essential. Chronic kidney disease (CKD) may influence this balance, lowering the usability of these grafts for vascular access in end-stage CKD patients on dialysis. We aimed to investigate the effects of CKD on in vivo scaffold breakdown and tissue formation in grafts made of electrospun, modular, supramolecular polycarbonate with ureido-pyrimidinone moieties (PC-UPy). We implanted PC-UPy aortic interposition grafts (n = 40) in a rat 5/6th nephrectomy model that mimics systemic conditions in human CKD patients. We studied patency, mechanical stability, extracellular matrix (ECM) components, total cellularity, vascular tissue formation, and vascular calcification in CKD and healthy rats at 2, 4, 8, and 12 weeks post-implantation. Our study shows successful in vivo application of a slow-degrading small-diameter vascular graft that supports adequate in situ vascular tissue formation. Despite systemic inflammation associated with CKD, no influence of CKD on patency (Sham: 95% vs CKD: 100%), mechanical stability, ECM formation (Sirius red⁺, Sham 16.5% vs CKD 25.0%-p:0.83), tissue composition, and immune cell infiltration was found. We did find a limited increase in vascular calcification at 12 weeks (Sham 0.08% vs CKD 0.80%-p:0.02) in grafts implanted in CKD animals. However, this was not associated with increased stiffness in the explants. Our findings suggest that disease-specific graft design may not be necessary for use in CKD patients on dialysis.

A versatile strategy to construct free-standing multi-furcated vessels and a complicated vascular network in heterogeneous porous scaffolds via combination of 3D printing and stimuli-responsive hydrogels

Mimicking complex structures of natural blood vessels and constructing vascular networks in tissue engineering scaffolds are still challenging now. Herein we demonstrate a new and versatile strategy to fabricate free-standing multi-furcated vessels and complicated vascular networks in heterogeneous porous scaffolds by integrating stimuli-responsive hydrogels and 3D printing technology. Through the sol-gel transition of temperature-responsive gelatin and conversion between two physical crosslinking networks of pH-responsive chitosan (i.e., electrostatic network between protonated chitosan and sulfate ion, crystalline network of neutral chitosan), physiologically-stable gelatin/chitosan hydrogel tubes can be constructed. While stimuli-responsive hydrogels confer the formation mechanism of the hydrogel tube, 3D printing confers the feasibility to create a multi-furcated structure and interconnected network in various heterogeneous porous scaffolds. As a consequence, biomimetic multi-furcated vessels (MFVs) and heterogeneous porous scaffolds containing multi-furcated vessels (HPS-MFVs) can be constructed precisely. Our data further confirm that the artificial blood vessel (gelatin/chitosan hydrogel tube) shows good physiological stability, mechanical strength, semi-permeability, hemocompatibility, cytocompatibility and low in vivo inflammatory response. Co-culture of hepatocyte (L02 cells) and human umbilical vein endothelial cells (HUVECs) in HPS-MFVs indicates the successful construction of a liver model. We believe that our method offers a simple and easy-going way to achieve robust fabrication of free-standing multi-furcated blood vessels and prevascularization of porous scaffolds for tissue engineering and regenerative medicine.

Polyvinyl alcohol coating prevents platelet adsorption and improves mechanical property of polycaprolactone-based small-caliber vascular graft

The low patency of synthetic vascular grafts hinders their practical applicability. Polyvinyl alcohol (PVA) is a non-toxic, highly hydrophilic polymer; thus, we created a PVA-coated polycaprolactone (PCL) nanofiber vascular graft (PVA–PCL graft). In this study, we examine whether PVA could improve the hydrophilicity of PCL grafts and evaluate its in vivo performance using a rat aorta implantation model. A PCL graft with an inner diameter of 1 mm is created using electrospinning (control). The PCL nanofibers are coated with PVA, resulting in a PVA–PCL graft. Mechanical property tests demonstrate that the PVA coating significantly increases the stiffness and resilience of the PCL graft. The PVA–PCL surface exhibits a much smaller sessile drop contact angle when compared with that of the control, indicating that the PVA coating has hydrophilic properties. Additionally, the PVA–PCL graft shows significantly less platelet adsorption than the control. The proposed PVA–PCL graft is implanted into the rat’s abdominal aorta, and its in vivo performance is tested at 8 weeks. The patency rate is 83.3% (10/12). The histological analysis demonstrates autologous cell engraftment on and inside the scaffold, as well as CD31/α-smooth muscle positive neointima regeneration on the graft lumen. Thus, the PVA–PCL grafts exhibit biocompatibility in the rat model, which suggests that the PVA coating is a promising approach for functionalizing PCL.

Insulin therapy maintains the performance of PVA-coated PCL grafts in a diabetic rat model

Vascular tissue engineering has shown promising results in "healthy" animal models. However, studies on the efficacy of artificial grafts under "pathological conditions" are limited. Therefore, in this study, we aimed to characterize the performance of polyvinyl alcohol (PVA)-coated poly-ε-caprolactone (PCL) grafts (PVA-PCL grafts) under diabetic conditions. To this end, PCL grafts were produced via electrospinning and coated with the hydrophilic PVA polymer, while a diabetic rat model (DM) was established via streptozotocin injection. Thereafter, the performance of the graft in the infrarenal abdominal aorta of the rats was evaluated in vivo. Thus, we observed that the healthy group showed CD31 positive/αSM positive cells in the graft lumen. Further, the patency rate of the PVA-PCL graft was 100% at 2 weeks (n = 7), while all the DM rats (n = 8) showed occluded grafts. However, the treatment of DM rats with neutral protamine Hagedorn insulin (tDM) significantly improved the patency rate (100%; n = 5). Furthermore, the intimal coverage rate corresponding to the tDM group was comparable to that of the healthy group at 2 weeks (tDM vs. healthy: 16.1% vs. 14.7%, p = 0.931). Therefore, the present study demonstrated that the performance of the PVA-PCL grafts was impaired in DM rats; however, insulin treatment reversed this impairment. These findings highlighted the importance of using a model that more closely resembles the cases that are encountered in clinical practice to achieve a clinically applicable vascular graft with a small diameter.

Impaired endothelial cell proliferative, migratory, and adhesive abilities are associated with the slow endothelialization of polycaprolactone vascular grafts implanted into a hypercholesterolemia rat model

Most small diameter vascular grafts (inner diameter<6 mm) evaluation studies are performed in healthy animals that cannot represent the clinical situation. Herein, an hypercholesterolemia (HC) rat model with thickened intima and elevated expression of pro-inflammatory intercellular adhesion molecular-1 (ICAM-1) in the carotid branch is established. Electrospun polycaprolactone (PCL) vascular grafts (length: 1 cm; inner diameter: 2 mm) are implanted into the HC rat abdominal aortas in an end to end fashion and followed up to 43 days, showing a relative lower patency accompanied by significant neointima hyperplasia, abundant collagen deposition, and slower endothelialization than those implanted into healthy ones. Moreover, the proliferation, migration, and adhesion behavior of endothelial cells (ECs) isolated from the HC aortas are impaired as evaluated under both static and pulsatile flow conditions. DNA microarray studies of the HC aortic endothelium suggest genes involved in EC proliferation (Egr2), apoptosis (Zbtb16 and Mt1), and metabolism (Slc7a11 and Hamp) are down regulated. These results suggest the impaired proliferative, migratory, and adhesive abilities of ECs are associated with the bad performances of grafts in HC rat. Future pre-clinical evaluation of small diameter vascular grafts may concern more disease animal models with clinical complications. STATEMENT OF SIGNIFICANCE: During the development of small diameter vascular grafts (D<6 mm), young and healthy animal models from pigs, sheep, dogs, to rabbits and rats are preferred. However, it cannot represent the clinic situation, where most cardiovascular grafting procedures are performed in the elderly and age is the primary risk factor for disease development or death. Herein, the performance of electrospun polycaprolactone (PCL) vascular grafts implanted into hypercholesterolemia (HC) or healthy rats were evaluated. Results suggest the proliferative, migratory, and adhesive abilities of endothelial cells (ECs) are already impaired in HC rats, which contributes to the observed slower endothelialization of implanted PCL grafts. Future pre-clinical evaluation of small diameter vascular grafts may concern more disease animal models with clinical complications.

Donor Heterogeneity in the Human Macrophage Response to a Biomaterial under Hyperglycemia in vitro

Macrophages have a commanding role in scaffold-driven in situ tissue regeneration. Depending on their polarization state, macrophages mediate the formation and remodeling of new tissue by secreting growth factors and cytokines. Therefore, successful outcomes of material-driven in situ tissue vascular tissue engineering depends largely on the immuno-regenerative potential of the recipient. A large cohort of patients requiring vascular replacements suffers from systemic multifactorial diseases, like diabetes, which gives rise to a hyperglycemic and aggressive oxidative inflammatory environment that is hypothesized to hamper a well-balanced regenerative process. Here, we aimed to fundamentally explore the effects of hyperglycemia, as one of the hallmarks of diabetes, on the macrophage response to 3D electrospun synthetic biomaterials for in situ tissue engineering, in terms of inflammatory profile and tissue regenerative capacity. To simulate the early phases of the in situ regenerative cascade, we used a bottom-up in vitro approach. Primary human macrophages (n=8 donors) and (myo)fibroblasts in mono- or co-culture were seeded in 2D, as well as in a 3D electrospun resorbable polycaprolactone bisurea (PCL-BU) scaffold and exposed to normoglycemic (5.5 mM glucose), hyperglycemic (25 mM glucose) and osmotic control conditions (5.5 mM glucose, 19.5 mM mannitol). The results showed that macrophage polarization by biochemical stimuli was effective under all glycemic conditions and that the polarization states dictated expression of the receptors SCL2A1 (glucose transporter 1) and CD36 (fatty acid transporter). In 3D, the macrophage response to hyperglycemic conditions was strongly donor-dependent in terms of phenotype, cytokine secretion profile, and metabolic receptor expression. When co-cultured with (myo)fibroblasts, hyperglycemic conditions led to an increased expression of fibrogenic markers (ACTA2, COL1, COL3, IL-1β). Together, these findings show that the hyperglycemic and hyperosmotic conditions may indeed influence the process of macrophage-driven in situ tissue engineering, and that the extent of this is likely to be patient-specific.

Animal studies for the evaluation of in situ tissue-engineered vascular grafts - a systematic review, evidence map, and meta-analysis

Vascular in situ tissue engineering (TE) is an approach that uses bioresorbable grafts to induce endogenous regeneration of damaged blood vessels. The evaluation of newly developed in situ TE vascular grafts heavily relies on animal experiments. However, no standard for in vivo models or study design has been defined, hampering inter-study comparisons and translational efficiency. To provide input for formulating such standard, the goal of this study was to map all animal experiments for vascular in situ TE using off-the-shelf available, resorbable synthetic vascular grafts. A literature search (PubMed, Embase) yielded 15,896 studies, of which 182 studies met the inclusion criteria (n = 5,101 animals). The reports displayed a wide variety of study designs, animal models, and biomaterials. Meta-analysis on graft patency with subgroup analysis for species, age, sex, implantation site, and follow-up time demonstrated model-specific variations. This study identifies possibilities for improved design and reporting of animal experiments to increase translational value.

Systematic Review of Tissue-Engineered Vascular Grafts

Pathologies related to the cardiovascular system are the leading causes of death worldwide. One of the main treatments is conventional surgery with autologous transplants. Although donor grafts are often unavailable, tissue-engineered vascular grafts (TEVGs) show promise for clinical treatments. A systematic review of the recent scientific literature was performed using PubMed (Medline) and Web of Science databases to provide an overview of the state-of-the-art in TEVG development. The use of TEVG in human patients remains quite restricted owing to the presence of vascular stenosis, existence of thrombi, and poor graft patency. A total of 92 original articles involving human patients and animal models were analyzed. A meta-analysis of the influence of the vascular graft diameter on the occurrence of thrombosis and graft patency was performed for the different models analyzed. Although there is no ideal animal model for TEVG research, the murine model is the most extensively used. Hybrid grafting, electrospinning, and cell seeding are currently the most promising technologies. The results showed that there is a tendency for thrombosis and non-patency in small-diameter grafts. TEVGs are under constant development, and research is oriented towards the search for safe devices.

Immuno-regenerative biomaterials for in situ cardiovascular tissue engineering - Do patient characteristics warrant precision engineering?

In situ tissue engineering using bioresorbable material implants - or scaffolds - that harness the patient's immune response while guiding neotissue formation at the site of implantation is emerging as a novel therapy to regenerate human tissues. For the cardiovascular system, the use of such implants, like blood vessels and heart valves, is gradually entering the stage of clinical translation. This opens up the question if and to what extent patient characteristics influence tissue outcomes, necessitating the precision engineering of scaffolds to guide patient-specific neo-tissue formation. Because of the current scarcity of human in vivo data, herein we review and evaluate in vitro and preclinical investigations to predict the potential role of patient-specific parameters like sex, age, ethnicity, hemodynamics, and a multifactorial disease profile, with special emphasis on their contribution to the inflammation-driven processes of in situ tissue engineering. We conclude that patient-specific conditions have a strong impact on key aspects of in situ cardiovascular tissue engineering, including inflammation, hemodynamic conditions, scaffold resorption, and tissue remodeling capacity, suggesting that a tailored approach may be required to engineer immuno-regenerative biomaterials for safe and predictive clinical applicability.

Small diameter polycaprolactone vascular grafts are patent in sheep carotid bypass but require antithrombotic therapy

Background: Polycaprolactone (PCL) scaffolds exhibit high biocompatibility and are attractive as vascular conduits. Materials & methods: PCL tubes were cultivated in bioreactor with human adipose regenerative cells to assess ex vivo cytocompatibility, whereas in vivo PCL tube patency was evaluated in sheep carotid bypass with and without antithrombotic treatment. Results: Ex vivo results revealed increasing adipose regenerative cells on PCL using dynamic bioreactor culturing. In vivo data showed that 67% (2/3) of grafts in the antithrombotic group were patent at day 28, while 100% (3/3) of control grafts were occluded already during the first week due to thrombosis. Histology showed that patent PCL grafts were recellularized by host cells. Conclusion: PCL tubes may work as small diameter vascular scaffolds under antithrombotic treatment.

In-vivo assessment of a tissue engineered vascular graft computationally optimized for target vessel compliance

Tissue engineered vascular grafts (TEVGs) have the ability to be tuned to match a target vessel's compliance, diameter, wall thickness, and thereby prevent compliance mismatch. In this work, TEVG compliance was manipulated by computationally tuning its layered composition or by manipulating a crosslinking agent (genipin). In particular, these three acelluluar TEVGs were compared: a compliance matched graft (CM_gel - high gelatin content); a hypocompliant PCL graft (HYPO_pcl - high polycaprolactone content); and a hypocompliant genipin graft (HYPO_gen - equivalent composition as CM_gel but hypocompliant via increased genipin crosslinking). All constructs were implanted interpositionally into the abdominal aorta of 21 Sprague Dawley rats (n=7, males=11, females=10) for 28 days, imaged in-vivo using ultrasound, explanted, and assessed for remodeling using immunofluorescence and two photon excitation fluorescence imaging. Compliance matched grafts remained compliance-matched in-vivo compared to the hypocompliant grafts through 4 weeks (p<0.05). Construct degradation and cellular infiltration was increased in the CM_gel and HYPO_gen TEVGs. Contractile smooth muscle cell markers in the proximal anastomosis of the graft were increased in the CM_gel group compared to the HYPO_pcl (p=0.007) and HYPO_gen grafts (p=0.04). Both hypocompliant grafts also had an increased pro-inflammatory response (increased ratio of CD163 to CD86 in the mid-axial location) compared to the CM_gel group. Our results suggest that compliance matching using a computational optimization approach leads to the improved acute (28 day) remodeling of TEVGs. To the authors' knowledge, this is the first in-vivo rat study investigating TEVGs that have been computationally optimized for target vessel compliance.

Advances of hydrogel dressings in diabetic wounds

The hydrogel dressings with various functions for diabetic wound treatment.

Electrospinning and Electrospun Nanofibers: Methods, Materials, and Applications

Electrospinning is a versatile and viable technique for generating ultrathin fibers. Remarkable progress has been made with regard to the development of electrospinning methods and engineering of electrospun nanofibers to suit or enable various applications. We aim to provide a comprehensive overview of electrospinning, including the principle, methods, materials, and applications. We begin with a brief introduction to the early history of electrospinning, followed by discussion of its principle and typical apparatus. We then discuss its renaissance over the past two decades as a powerful technology for the production of nanofibers with diversified compositions, structures, and properties. Afterward, we discuss the applications of electrospun nanofibers, including their use as "smart" mats, filtration membranes, catalytic supports, energy harvesting/conversion/storage components, and photonic and electronic devices, as well as biomedical scaffolds. We highlight the most relevant and recent advances related to the applications of electrospun nanofibers by focusing on the most representative examples. We also offer perspectives on the challenges, opportunities, and new directions for future development. At the end, we discuss approaches to the scale-up production of electrospun nanofibers and briefly discuss various types of commercial products based on electrospun nanofibers that have found widespread use in our everyday life.

Formation of pressurizable hydrogel-based vascular tissue models by selective gelation in composite PDMS channels

Vascular tissue models created in vitro are of great utility in the biomedical research field, but versatile, facile strategies are still under development. In this study, we proposed a new approach to prepare vascular tissue models in PDMS-based composite channel structures embedded with barium salt powders. When a cell-containing hydrogel precursor solution was continuously pumped in the channel, the precursor solution in the vicinity of the channel wall was selectively gelled because of the barium ions as the gelation agent supplied to the flow. Based on this concept, we were able to prepare vascular tissue models, with diameters of 1–2 mm and with tunable morphologies, composed of smooth muscle cells in the hydrogel matrix and endothelial cells on the lumen. Perfusion culture was successfully performed under a pressurized condition of ∼120 mmHg. The presented platform is potentially useful for creating vascular tissue models that reproduce the physical and morphological characteristics similar to those of vascular tissues in vivo.

A new approach for the preparation of vascular tissue models in PDMS-based composite channel structures embedded with barium salt powders.

MSC-derived sEVs enhance patency and inhibit calcification of synthetic vascular grafts by immunomodulation in a rat model of hyperlipidemia

Vascular grafts often exhibit low patency rates in clinical settings due to the pathological environment within the patients requiring the surgery. Mesenchymal stem cell (MSC)-derived small extracellular vesicles (sEVs) have attracted increasing attention. These sEVs contain many potent signaling molecules that play important roles in tissue regeneration, such as microRNA and cytokines. In this study, a sEVs-functionalized vascular graft was developed, and in vivo performance was systematically evaluated in a rat model of hyperlipidemia. Electrospun poly (ε-caprolactone) (PCL) vascular grafts were first modified with heparin, to enhance the anti-thrombogenicity. MSC-derived sEVs were loaded onto the heparinized PCL grafts to obtain functional vascular grafts. As-prepared vascular grafts were implanted to replace a segment of rat abdominal artery (1 cm) for up to 3 months. Results showed that the incorporation of MSC-derived sEVs effectively inhibited thrombosis and calcification, thus enhancing the patency of vascular grafts. Furthermore, regeneration of the endothelium and vascular smooth muscle was markedly enhanced, as attributed to the bioactive molecules within the sEVs, including vascular endothelial growth factor (VEGF), miRNA126, and miRNA145. More importantly, MSC-derived sEVs demonstrated a robust immunomodulatory effect, that is, they induced the transition of macrophages from a pro-inflammatory and atherogenic (M1) phenotype to an anti-inflammatory and anti-osteogenic (M2c) phenotype. This phenotypic switch was confirmed in both in vitro and in vivo analyses. Taken together, these results suggest that fabrication of vascular grafts with immunomodulatory function can provide an effective approach to improve vascular performance and functionality, with translational implication in cardiovascular regenerative medicine.

Coaxially-structured fibres with tailored material properties for vascular graft implant

Readily-available small-diameter arterial grafts require a great combination of materials properties, including high strength, compliance, suturability, blood sealing and anti-thrombogenicity, as well as anti-kinking property for those used in challenging anatomical situations. We have constructed grafts composed of coaxially-structured polycaprolactone (PCL)/gelatin nanofibres, and tailored the material structures to achieve high strength, compliance and kink resistance, as well as excellent water sealing and anti-thrombogenicity. Coaxially-structured fibres in the grafts provided mechanical stability through the core, while flexibility and cell adhesion through the sheath. Results showed that graft compliance increased while strength decreased with the concentration ratio between core and sheath polymers. Compared to pure PCL fibrous surfaces, coaxial PCL/gelatin fibrous surfaces potently inhibited platelet adhesion and activation, providing excellent anti-thrombogenicity. To render sufficient burst strength and suturability, an additional layer of pure PCL was necessary to cap the layer of coaxial PCL/gelatin fibres. The two-layered grafts with the wall thickness comparable to native arteries demonstrated artery-like compliance and kink resistance, properties important to arteries under complex mechanical loading. The in vivo evaluation was performed using the interposition carotid artery graft model in rabbits for three months. Interestingly, results from ultrasonic imaging and histological analysis demonstrated that the two-layered grafts with a thinner outer PCL layer, which possessed higher compliance and kink resistance, showed increased blood flow, minimal lumen reduction and fibrosis. All vascular grafts exhibited patency and induced limited cell infiltration. Together, we presented a facile and useful approach to fabricate vascular grafts with superior graft performances, biomechanical properties, and blood compatibility. Grafts with artery-like compliance and flexibility have demonstrated improved implantation outcomes.

Quickening: Translational design of resorbable synthetic vascular grafts

Traditional tissue-engineered vascular grafts have yet to gain wide clinical use. The difficulty of scaling production of these cell- or biologic-based products has hindered commercialization. In situ tissue engineering bypasses such logistical challenges by using acellular resorbable scaffolds. Upon implant, the scaffolds become remodeled by host cells. This review describes the scientific and translational advantages of acellular, synthetic vascular grafts. It surveys in vivo results obtained with acellular synthetics over their fifty years of technological development. Finally, it discusses emerging principles, highlights strategic considerations for designers, and identifies questions needing additional research.

Can We Grow Valves Inside the Heart? Perspective on Material-based In Situ Heart Valve Tissue Engineering

In situ heart valve tissue engineering using cell-free synthetic, biodegradable scaffolds is under development as a clinically attractive approach to create living valves right inside the heart of a patient. In this approach, a valve-shaped porous scaffold "implant" is rapidly populated by endogenous cells that initiate neo-tissue formation in pace with scaffold degradation. While this may constitute a cost-effective procedure, compatible with regulatory and clinical standards worldwide, the new technology heavily relies on the development of advanced biomaterials, the processing thereof into (minimally invasive deliverable) scaffolds, and the interaction of such materials with endogenous cells and neo-tissue under hemodynamic conditions. Despite the first positive preclinical results and the initiation of a small-scale clinical trial by commercial parties, in situ tissue formation is not well understood. In addition, it remains to be determined whether the resulting neo-tissue can grow with the body and preserves functional homeostasis throughout life. More important yet, it is still unknown if and how in situ tissue formation can be controlled under conditions of genetic or acquired disease. Here, we discuss the recent advances of material-based in situ heart valve tissue engineering and highlight the most critical issues that remain before clinical application can be expected. We argue that a combination of basic science - unveiling the mechanisms of the human body to respond to the implanted biomaterial under (patho)physiological conditions - and technological advancements - relating to the development of next generation materials and the prediction of in situ tissue growth and adaptation - is essential to take the next step towards a realistic and rewarding translation of in situ heart valve tissue engineering.

Challenges in vascular tissue engineering for diabetic patients

Hyperglycemia and dyslipidemia coexist in diabetes and result in inflammation, degeneration, and impaired tissue remodeling, processes which are not conducive to the desired integration of tissue engineered products into the surrounding tissues. There are several challenges for vascular tissue engineering such as non-thrombogenicity, adequate burst pressure and compliance, suturability, appropriate remodeling responses, and vasoactivity, but, under diabetic conditions, an additional challenge needs to be considered: the aggressive oxidative environment generated by the high glucose and lipid concentrations that lead to the formation of advanced glycation end products (AGEs) in the vascular wall. Extracellular matrix-based scaffolds have adequate physical properties and are biocompatible, however, these scaffolds are altered in diabetes by the formation AGEs and impaired collagen degradation, consequently increasing vascular wall stiffness. In addition, vascular cells detect and respond to altered stimuli from the matrix by pathological remodeling of the vascular wall. Due to the immunomodulatory effects of mesenchymal stem cells (MSCs), they are frequently used in tissue engineering in order to protect the scaffolds from inflammation. MSCs together with antioxidant treatments of the scaffolds are expected to protect the vascular grafts from diabetes-induced alterations. In conclusion, as one of the most daunting environments that could damage the ECM and its interaction with cells is progressively built in diabetes, we recommend that cells and scaffolds used in vascular tissue engineering for diabetic patients are tested in diabetic animal models, in order to obtain valuable results regarding their resistance to diabetic adversities.

STATEMENT OF SIGNIFICANCE

Almost 25 million Americans have diabetes, characterized by high levels of blood sugar that binds to tissues and disturbs the function of cardiovascular structures. Therefore, patients with diabetes have a high risk of cardiovascular diseases. Surgery is required to replace diseased arteries with implants, but these fail after 5-10 years because they are made of non-living materials, not resistant to diabetes. New tissue engineering materials are developed, based on the patients' own stem cells, isolated from fat, and added to extracellular matrix-based scaffolds. Our main concern is that diabetes could damage the tissue-like implants. Thus we review studies related to the effect of diabetes on tissue components and recommend antioxidant treatments to increase the resistance of implants to diabetes.

Biomaterial-driven in situ cardiovascular tissue engineering-a multi-disciplinary perspective

There is a persistent and growing clinical need for readily-available substitutes for heart valves and small-diameter blood vessels. In situ tissue engineering is emerging as a disruptive new technology, providing ready-to-use biodegradable, cell-free constructs which are designed to induce regeneration upon implantation, directly in the functional site. The induced regenerative process hinges around the host response to the implanted biomaterial and the interplay between immune cells, stem/progenitor cell and tissue cells in the microenvironment provided by the scaffold in the hemodynamic environment. Recapitulating the complex tissue microstructure and function of cardiovascular tissues is a highly challenging target. Therein the scaffold plays an instructive role, providing the microenvironment that attracts and harbors host cells, modulating the inflammatory response, and acting as a temporal roadmap for new tissue to be formed. Moreover, the biomechanical loads imposed by the hemodynamic environment play a pivotal role. Here, we provide a multidisciplinary view on in situ cardiovascular tissue engineering using synthetic scaffolds; starting from the state-of-the art, the principles of the biomaterial-driven host response and wound healing and the cellular players involved, toward the impact of the biomechanical, physical, and biochemical microenvironmental cues that are given by the scaffold design. To conclude, we pinpoint and further address the main current challenges for in situ cardiovascular regeneration, namely the achievement of tissue homeostasis, the development of predictive models for long-term performances of the implanted grafts, and the necessity for stratification for successful clinical translation.