Arterial prosthetic materials

Vascular Grafts: Technology Success/Technology Failure

Vascular prostheses (grafts) are widely used for hemodialysis blood access, trauma repair, aneurism repair, and cardiovascular reconstruction. However, smaller-diameter (≤4 mm) grafts that would be valuable for many reconstructions have not been achieved to date, although hundreds of papers on small-diameter vascular grafts have been published. This perspective article presents a hypothesis that may open new research avenues for the development of small-diameter vascular grafts. A historical review of the vascular graft literature and specific types of vascular grafts is presented focusing on observations important to the hypothesis to be presented. Considerations in critically reviewing the vascular graft literature are discussed. The hypothesis that perhaps the "biocompatible biomaterials" comprising our vascular grafts-biomaterials that generate dense, nonvascularized collagenous capsules upon implantation-may not be all that biocompatible is presented. Examples of materials that heal with tissue reconstruction and vascularity, in contrast to the fibrotic encapsulation, are offered. Such prohealing materials may lead the way to a new generation of vascular grafts suitable for small-diameter reconstructions.

Engineering Vessels as Good as New?

Blood vessels convey essential nutrients to end organs, and when diseased, they must be replaced or bypassed. Traditionally plastic and synthetic materials have been used but are susceptible to thrombosis, stenosis, and poor patency rates. A recent report in Science Translational Medicine describes a decellularized matrix grown in vitro from commercially sourced fibroblasts that can be used as a vascular graft. Fibroblasts are grown for several weeks on a fibrin scaffold, laying down a collagen layer. After decellularization and transplantation as an arteriovenous fistula, this group showed that grafts remained patent for several weeks. The lack of cellular material in this graft at the time of transplantation reduced the risk of immune rejection. The matrix laid down by the fibroblasts can serve as a scaffold for recipient cells to colonize after implantation, but also provides structural support for arterial blood flow. Other tissue-engineered grafts of decellularized matrices have recently been tested in clinical trial. For these strategies, the cell type, scaffold material, and culture conditions are key components that dictate not only the type and quality of the end product, but also allow standardization and quality control necessary for widespread translation into clinical use. These off-the-shelf decellularized products may be the first in a new generation of therapies for patients with cardiovascular disease.

Electrospinning of collagen/biopolymers for regenerative medicine and cardiovascular tissue engineering

The process of electrospinning has seen a resurgence of interest in the last few decades which has led to a rapid increase in the amount of research devoted to its use in tissue engineering applications. Of this research, the area of cardiovascular tissue engineering makes up a large percentage, with substantial resources going towards the creation of bioresorbable vascular grafts composed of electrospun nanofibers of collagen and other biopolymers. These bioresorbable grafts have compositions that allow for the in situ remodeling of the structure, with the eventual replacement of the graft with completely autologous tissue. This review will highlight some of the work done in the field of electrospinning for cardiovascular applications, with an emphasis on the use of biopolymers such as collagens, elastin, gelatin, fibrinogen, and silk fibroin, as well as biopolymers used in combination with resorbable synthetic polymers.

Impregnated polyester arterial prostheses: performance and prospects

Impregnated polyester arterial prostheses have gained wide acceptance by most vascular surgery teams, probably because these prostheses are easy to use, without any preclotting. We offer here a synthesis of the main studies that have appraised the experimental and clinical performance of these prostheses, and we delineate their major prospects.

Bicomponent vascular grafts consisting of synthetic absorbable fibers: Part II: In vivo healing response

The objectives of this research were (1) to determine whether the use of partially absorbable vascular grafts would improve their nonthrombogenic performance and whether they are more prone to aneurysmal dilation and subsequent failure in vivo, and (2) to find out the relationships, if any, between these in vivo and the previously reported in vitro data with an emphasis on how the in vitro changes in fabric structure and properties related to these in vivo data. Bicomponent vascular fabrics were made from Dacron and polyglycolic acid (PGA) yarns with a range of composition ratios of the PGA to Dacron. Both woven and single Jersey knit fabrics were made, and implanted in dogs for 4 months. The following findings and relationships were obtained. (1) The bicomponent vascular fabrics resulted in a full-wall healing in the thoracic aorta of dogs. All bicomponent vascular grafts in survived dogs exhibited 100% patency, no thrombus or aneurysmal formation, no hematoma or seroma around the grafts, and no fibrin coagula in the inner capsules. The gross morphology of the regenerated tissues was very similar visually to the adjacent original arterial tissue. Histologically, the luminal surface was lined with a layer of endothelial cells with myofibroblasts, fibroblasts, and collagens underneath. (2) The extent of the full-wall healing depended on the type of fabric structure, the concentration of absorbable yarns, the location of absorbable yarns (for the woven group only), and initial water permeability. It is believed that the concentration effect was related to the level of macrophage activation from the degradation products of the absorbable yarns, while the location effect was attributed to the various types of fabric structure change on the degradation of the absorbable yarns. (3) In general, the knitted group (K), was better than the woven group (W). K3 showed the best in vivo performance in the knitted group. (4) In the woven group, W3 was the best. The incorporation of absorbable yarns in the weft direction of the bicomponent fabrics (W3) resulted in a velourlike, loose and porous fabric surface for facilitating tissue ingrowth. The placement of absorbable yarns in the warp direction (W1), however, did not show this unique surface morphology. Calcification was, however, occasionally observed in the woven samples with low initial water permeability. These observed in vivo performances correlated well with our previously reported in vitro study.

Mathematical modeling of water permeability of surgical fabrics for vascular use

The purpose of this study was to derive new mathemtic formulae that could be used reliably to predict water permeability of surgical fabrics before they are made and tested for water permeability. Such a theoretical prediction of water permeability, Qprd, of surgical fabrics is needed for not only timely characterization but also for assisting in more efficient future design and development of better surgical fabrics. Two mathematic formulae, Qw and Qk, were derived from the Buckingham Pi Theorem, in which relevant fiber and fabric parameters were placed into dimensionless pi groups and computed for 25 commercial and experimental vascular fabrics. Linear regression analysis of the relationship between these pi groups with water permeability on the woven and knitted grafts yielded coefficients for the corresponding pi groups that were required for constructing appropriate mathematic formulae to predict water permeability of vascular fabrics. When proper sources of the experimentally determined water permeability, Qexp, were chosen for comparison, we found that 86% of woven fabrics (6 of 7) and 77% of knitted fabrics (14 of 18) had their Qprd within 10% of their Qexp. This high percentage of close matching (within 10%) between Qprd and Qexp should be considered satisfactory because the experimental error for obtaining Qexp is generally higher than 10%. The difference between Qprd and Qexp ranged from as small as 0.27% to as high as 74.2%, depending on the type of fabrics and source of Qexp.(ABSTRACT TRUNCATED AT 250 WORDS)

Bicomponent vascular grafts consisting of synthetic absorbable fibers. I. In vitro study

The objective of this study is to determine the effects of the location and concentration of synthetic absorbable yarn components in bicomponent vascular graft fabrics on their structure and properties in a controlled in vitro hydrolytic environment. Bicomponent vascular fabrics were made from Dacron and polyglycolic acid (PGA) yarns with a range of composition ratios of PGA to Dacron and a range of locations of PGA. Both woven and single jersey knit fabrics were made. These fabrics were characterized by standard textile methods and subject to in vitro hydrolytic degradation study. In vitro hydrolytic degradation study showed that the most dramatic changes in the bicomponent fabric characteristics and properties occurred 30 and 60 days of hydrolysis. This schedule coincided with the hydrolytic degradation rate of PGA absorbable sutures. In the woven (W) group, the incorporation of absorbable yarns in the weft direction (W3) of the bicomponent fabrics resulted in the velour-like, loose, and porous surface morphology of the fabric for potential subsequent tissue ingrowth, while those woven fabrics with absorbable yarns in the warp direction (W1) did not have this unique velour-like surface. In the knitted (K) group, the concentration of absorbable yarns appeared to be closely related to the observed changes in fabric properties and structure. The incorporation of absorbable yarns into knitted fabrics did not result in the same level change in fabric structure and property as woven fabrics. In both W and K groups, a minimal level of mechanical strength of the fabrics was maintained due to the remaining Dacron yarns. Structural integrity of these fabrics was retained at the end of hydrolytic degradation study. The data obtained could be used to correlate with the subsequent in vivo performance of these bicomponent vascular grafts. If correlations exist, they could be used to improve the design of future bicomponent vascular grafts for improved performance.

Morphological changes of poly(ethylene terephthalate) on multiple steam sterilization

Poly(ethylene terephthalate) (PET) was steam sterilized by autoclaving for 15, 30 and 60 min. The thermal properties, T m, delta-H and percent crystallinity were determined using differential scanning calorimetry. Molecular weight distribution was determined using gel permeation liquid chromatography. Crystallinity of PET was also monitored by infrared spectrophotometry. The analyses indicate that that chain scission and cyclization reactions take place in PET, forming cyclic oligomers, that can migrate to the polymer surface and which may affect long term performance of PET.

Perioperative suppression of platelet adherence to small-diameter polytetrafluoroethylene (PTFE) grafts

The perioperative effect of platelet antagonists on small-diameter polytetrafluoroethylene (PTFE) grafts was evaluated in forty-six New Zealand white male rabbits receiving either dipyridamole (DPM) 100 mg/kg/day (n = 10; group 1), aspirin (ASA) 10 mg/kg/day (n = 10; group 2), a combination of ASA 10 mg/kg/day and DPM 10 mg/kg/day (n = 9; group 3) or 100 mg/kg/day (n = 10; group 4), or placebo (n = 7) as single daily doses. All regimens began 72 hr prior to insertion of a 20 x 3-mm internal diameter PTFE interposition aortic graft. Autologous indium-111 labeled platelets were injected immediately after implantation. Graft and an equivalent segment of aorta were harvested after 48 hr. Graft platelet adherence index (GPAI) was calculated as the graft:reference aorta ratio of emissions. The GPAI in the control group was 238 +/- 46 (mean +/- SD). Single regimen antiplatelet agents in groups 1 and 2 reduced mean GPAI to 47 +/- 38 and 40 +/- 12, respectively. The combination regimen in group 3 lowered mean GPAI to 43 +/- 8 and in group 4 to 21 +/- 7. Platelet uptake in PTFE grafts at 48 hr is significantly lowered to 8.8 to 19.7% of control by perioperative antiplatelet agents given as a single daily oral dose (P less than 0.001). ASA alone and DPM alone provided similar suppression of platelet uptake, but combination ASA + low dose or high dose DPM gave significantly greater (P less than 0.001) suppression of early platelet deposition than the single agent regimens. These results support perioperative administration of combination oral antiplatelet agents as adjunctive therapy in small diameter prosthetic graft implantation.

Normal wound healing compared to healing within porous Dacron implants

This study examined the hypothesis that healing within porous implants differs from that in normal connective tissue. Special attention was given to extracellular components including collagen, reticular fibers, and ground substance, and to enzymes associated with activated macrophages. Using Dacron velour and the rabbit as host, the healing of normal connective tissue and that of the tissue/implant interface were histologically compared 10 and 28 days postimplantation. The results exhibited significant differences between connective tissue healing, implant capsule formation, and granulation tissue generation. The healing of connective tissue and implant capsule formation were essentially complete at 28 days. However, tissue inside the implant was qualitatively different and did not significantly change between 10 and 28 days. It was characterized by macrophages and giant cells, a predominantly acid mucopolysaccharide ground substance, and qualitatively fewer and less well defined collagen and reticular fibers were observed than in normal wound healing. Thus we conclude that the connective tissue inside Dacron velour does not resemble normal connective tissue after 10 or 28 days of healing. Furthermore, the collagen never fully matures into orderly bundles, a phenomenon which may be related to an altered mucopolysaccharide composition and a diminished reticular network. The lysosomal enzymatic activity of the macrophages and perhaps the giant cells at the tissue/implant interface may be linked to these differences.

Textile arterial prostheses: is water permeability equivalent to porosity?

Porosity and water permeability are two distinct terms that describe different characteristics of vascular prostheses. The porosity is a measure of the void fraction within the prosthesis wall and is believed to give a rough prediction of the capacity of the graft to anchor newly formed surrounding tissue after implantation, whereas the water permeability indicates the rate at which water can flow through the prosthesis wall and, when measured under physiological pressure conditions, provides the surgeon with information about the need for preclotting prior to implantation. The literature has not always clearly distinguished between these two terms, and some authors in fact have suggested that they both refer to the same property of a prosthesis. In an attempt to clarify the issue, porosity and water permeability measurements were made on 34 commercial vascular prostheses having different textile constructions. Linear regression analysis demonstrated that these two characteristics are only weakly related (r = 0.59). It is therefore recommended that the current draft standards for such devices reference both properties: porosity and water permeability.

History of (micro) vascular surgery and the development of small-caliber blood vessel prostheses (with some notes on patency rates and re-endothelialization)

The historical development of vascular surgery is reviewed from ancient times (Ruphus of Ephesus, Aëtius of Amida) to recent developments (sutured anastomosis by Carrel). Attempts to anastomose blood vessels by means of nonsuturing technique, using a ring or short tube of diverse materials called prostheses, were undertaken at the start of this century and continued until shortly after World War II. With the advent of modern polymeric materials, prostheses of different types, sizes, structures, and fabrics have been used to substitute for blood vessels, both experimentally and clinically. Recently, blood vessel prostheses with small (1-1.5 mm) internal diameters became available and have been implanted experimentally. Patency rates, biophysical and structural properties, the re-endothelialization and the neointima formation of several types of microvascular prostheses are briefly reviewed.

Dacron as arterial prosthetic material: nature, properties, brands, fate and perspectives

Dacron graft prostheses are routinely implanted to overcome impairment of arterial flow to distal tissues. Many different fabric configurations have been developped and evaluated. Unfortunately, after implantation the flow surface of any graft persists as a fibrinous lining. No human specimen has a commonly ingrown extension of tissue exceeding some millimeters in length. Full wall healing and endothelialization of arterial prosthesis is a goal that must be pursued intensively because it seems that the goal is attainable.

Evaluation of prosthetic grafts of different porosity for arterial reconstruction

Autogenous jugular veins and Dacron grafts of different porosities were implanted as short bypass grafts around ligated femoral arteries in the dog. Patency rates for periods up to eight months were: vein, 79 per cent; DeBakey Dacron (lowest porosity), 39 per cent; Wesolowski Weavenit (imtermediate porosity), 56 per cent; high porosity Dacron, 8 per cent. The failure of sixteen of the twenty-four high porosity grafts was related to perigraft hematomas that occurred two to seven days after operation and later thrombosis. The higher the porosity of the graft, the better the healing pattern as evidenced by fibrous bonding of the inner and outer linings of the grafts through the interstices. In the spectrum of grafts with increasing porosity there is apparently an optimal porosity beyond which late bleeding counterbalances the better healing properties of the higher porosity graft.