3D Printing of Polymeric Bioresorbable Stents: A Strategy to Improve Both Cellular Compatibility and Mechanical Properties

Evaluation of the interface of metallic-coated biodegradable polymeric stents with prokaryotic and eukaryotic cells

Polymeric coronary stents, like the ABSORB™, are commonly used to treat atherosclerosis due to their bioresorbable and cell-compatible polymer structure. However, they face challenges such as high strut thickness, high elastic recoil, and lack of radiopacity. This study aims to address these limitations by modifying degradable stents produced by additive manufacturing with poly(lactic acid) (PLA) and poly(ε-caprolactone) (PCL) with degradable metallic coatings, specifically zinc (Zn) and magnesium (Mg), deposited via radiofrequency (rf) magnetron sputtering. The characterisation included the evaluation of the degradation of the coatings, antibacterial, anti-thrombogenicity, radiopacity, and mechanical properties. The results showed that the metallic coatings inhibited bacterial growth, though Mg exhibited a high degradation rate. Thrombogenicity studies showed that Zn-coated stents had anticoagulant properties, while Mg-coated and controls were thrombogenic. Zn coatings significantly improved radiopacity, enhancing contrast by 43 %. Mechanical testing revealed that metallic coatings reduced yield strength and, thus, diminished elastic recoil after stent expansion. Zn-coated stents improved cyclic compression resistance by 270 % for PCL stents, with PLA-based stents showing smaller improvements. The coatings also enhanced crush resistance, particularly for Zn-coated PCL stents. Overall, Zn-coated polymers have emerged as the premier prototype due to their superior biological and mechanical performance, appropriate degradation during the stent life, and ability to provide the appropriate radiopacity to medical devices.

Moving away from metal: Step toward the future with bioresorbable vascular scaffolds and novel antiproliferative agents

Background

Peripheral arterial disease (PAD) is a common source of morbidity and mortality globally and is expected to raise increase in prevalence. Many endovascular techniques exist to manage PAD; however, there remains room for improvement, especially as it relates to below-the-knee vessels. Recent evidence and devices are leading to a resurgence of interest in bioresorbable vascular scaffolds and the -limus family of antiproliferative drugs in the PAD treatment space.

Methods

This nonsystematic review examines emerging technology for treatment of PAD with a specific focus on below-the-knee vessels and bioresorbable vascular scaffolds. Additional emerging and early technology such as novel delivery platforms are also briefly discussed with directions of future research highlighted.

Results

Bioresorbable vascular scaffold biomechanics and history are highlighted. Foundational knowledge of antiproliferative agents and evolving agents in peripheral vascular disease are also described.

Conclusions

Bioresorbable vascular scaffolds are an additional endovascular tool for the treatment of peripheral vascular disease. The integration with an antiproliferative agent may result in improved patency and performance; however, there is a paucity of data in the literature at present.

Biliary stents for active materials and surface modification: Recent advances and future perspectives

Demand for biliary stents has expanded with the increasing incidence of biliary disease. The implantation of plastic or self-expandable metal stents can be an effective treatment for biliary strictures. However, these stents are nondegradable and prone to restenosis. Surgical removal or replacement of the nondegradable stents is necessary in cases of disease resolution or restenosis. To overcome these shortcomings, improvements were made to the materials and surfaces used for the stents. First, this paper reviews the advantages and limitations of nondegradable stents. Second, emphasis is placed on biodegradable polymer and biodegradable metal stents, along with functional coatings. This also encompasses tissue engineering & 3D-printed stents were highlighted. Finally, the future perspectives of biliary stents, including pro-epithelialization coatings, multifunctional coated stents, biodegradable shape memory stents, and 4D bioprinting, were discussed.

3D printing technology and its revolutionary role in stent implementation in cardiovascular disease

Cardiovascular disease (CVD), exemplified by coronary artery disease (CAD), is a global health concern, escalating in prevalence and burden. The etiology of CAD is intricate, involving different risk factors. CVD remains a significant cause of mortality, driving the need for innovative interventions like percutaneous coronary intervention and vascular stents. These stents aim to minimize restenosis, thrombosis, and neointimal hyperplasia while providing mechanical support. Notably, the challenges of achieving ideal stent characteristics persist. An emerging avenue to address this involves enhancing the mechanical performance of polymeric bioresorbable stents using additive manufacturing techniques And Three-dimensional (3D) printing, encompassing various manufacturing technologies, has transcended its initial concept to become a tangible reality in the medical field. The technology's evolution presents a significant opportunity for pharmaceutical and medical industries, enabling the creation of targeted drugs and swift production of medical implants. It revolutionizes medical procedures, transforming the strategies of doctors and surgeons. Patient-specific 3D-printed anatomical models are now pivotal in precision medicine and personalized treatment approaches. Despite its ongoing development, additive manufacturing in healthcare is already integrated into various medical applications, offering substantial benefits to a sector under pressure for performance and cost reduction. In this review primarily emphasizes stent technology, different types of stents, highlighting its application with some potential complications. Here we also address their benefits, potential issues, effectiveness, indications, and contraindications. In future it can potentially reduce complications and help in improving patients' outcomes. 3DP technology offers the promise to customize solutions for complex CVD conditions and help or fostering a new era of precision medicine in cardiology.

Supercritical Impregnation of PETG with Olea europaea Leaf Extract: Influence of Operational Parameters on Expansion Degree, Antioxidant and Mechanical Properties

PETG (poly(ethylene glycol-co-cyclohexane-1,4-dimethanol terephthalate)) is an amorphous copolymer, biocompatible, recyclable, and versatile. Nowadays, it is being actively researched for biomedical applications. However, proposals of PETG as a platform for the loading of bioactive compounds from natural extract are scarce, as well as the effect of the supercritical impregnation on this polymer. In this work, the supercritical impregnation of PETG filaments with Olea europaea leaf extract was investigated, evaluating the effect of pressure (100-400 bar), temperature (35-55 °C), and depressurization rate (5-50 bar min-1) on the expansion degree, antioxidant activity, and mechanical properties of the resulting filaments. PETG expansion degree ranged from ~3 to 120%, with antioxidant loading ranging from 2.28 to 17.96 g per 100 g of polymer, corresponding to oxidation inhibition values of 7.65 and 66.55%, respectively. The temperature and the binary interaction between pressure and depressurization rate most affected these properties. The mechanical properties of PETG filaments depended greatly on process variables. Tensile strength values were similar or lower than the untreated filaments. Young's modulus and elongation at break values decreased below ~1000 MPa and ~10%, respectively, after the scCO2 treatment and impregnation. The extent of this decrease depended on the supercritical operational parameters. Therefore, filaments with higher antioxidant activity and different expansion degrees and mechanical properties were obtained by adjusting the supercritical processing conditions.

Polymer-Drug Anti-Thrombogenic and Hemocompatible Coatings as Surface Modifications

Since the 1960s, efforts have been made to develop new technologies to eliminate the risk of thrombosis in medical devices that come into contact with blood. Preventing thrombosis resulting from the contact of a medical device, such as an implant, with blood is a challenge due to the high mortality rate of patients and the high cost of medical care. To this end, various types of biomaterials coated with polymer-drug layers are being designed to reduce their thrombogenicity and improve their hemocompatibility. This review presents the latest developments in the use of polymer-drug systems to produce anti-thrombogenic surfaces in medical devices in contact with blood, such as stents, catheters, blood pumps, heart valves, artificial lungs, blood vessels, blood oxygenators, and various types of tubing (such as for hemodialysis) as well as microfluidic devices. This paper presents research directions and potential clinical applications, emphasizing the importance of continued progress and innovation in the field.

Recent development and future application of biodegradable ureteral stents

Ureteral stenting is a common clinical procedure for the treatment of upper urinary tract disorders, including conditions such as urinary tract infections, tumors, stones, and inflammation. Maintaining normal renal function by preventing and treating ureteral obstruction is the primary goal of this procedure. However, the use of ureteral stents is associated with adverse effects, including surface crusting, bacterial adhesion, and lower urinary tract symptoms (LUTS) after implantation. Recognizing the need to reduce the complications associated with permanent ureteral stent placement, there is a growing interest among both physicians and patients in the use of biodegradable ureteral stents (BUS). The evolution of stent materials and the exploration of different stent coatings have given these devices different roles tailored to different clinical needs, including anticolithic, antibacterial, antitumor, antinociceptive, and others. This review examines recent advances in BUS within the last 5 years, providing an in-depth analysis of their characteristics and performance. In addition, we present prospective insights into the future applications of BUS in clinical settings.

Biomimicking Atherosclerotic Vessels: A Relevant and (Yet) Sub-Explored Topic

Atherosclerosis represents the etiologic source of several cardiovascular events, including myocardial infarction, cerebrovascular accidents, and peripheral artery disease, which remain the leading cause of mortality in the world. Numerous strategies are being delineated to revert the non-optimal projections of the World Health Organization, by both designing new diagnostic and therapeutic approaches or improving the interventional procedures performed by physicians. Deeply understanding the pathological process of atherosclerosis is, therefore, mandatory to accomplish improved results in these trials. Due to their availability, reproducibility, low expensiveness, and rapid production, biomimicking physical models are preferred over animal experimentation because they can overcome some limitations, mainly related to replicability and ethical issues. Their capability to represent any atherosclerotic stage and/or plaque type makes them valuable tools to investigate hemodynamical, pharmacodynamical, and biomechanical behaviors, as well as to optimize imaging systems and, thus, obtain meaningful prospects to improve the efficacy and effectiveness of treatment on a patient-specific basis. However, the broadness of possible applications in which these biomodels can be used is associated with a wide range of tissue-mimicking materials that are selected depending on the final purpose of the model and, consequently, prioritizing some materials' properties over others. This review aims to summarize the progress in fabricating biomimicking atherosclerotic models, mainly focusing on using materials according to the intended application.

A novel double arrowhead auxetic coronary stent

A stent implantation is a standard medical procedure for treating coronary artery diseases. Over the years, various different designs have been explored for the stents which come with a range of limitations, including late in-stent restenosis (due to low radial strength), foreshortening, radial recoil, etc. Contrary, stents with auxetic design, characterized by a negative Poisson's ratio, display unique deformation characteristics that result in enhanced mechanical properties in terms of its radial strength, radial recoil, foreshortening, and more. In this study, we have analysed a novel double arrowhead (DA) auxetic stent that aims to overcome the limitations associated with traditional stents, specifically in terms of radial strength, foreshortening, and radial recoil. The parametric analysis was done initially on the DA's unit ring structure to optimize the design by evaluating the effect of three design parameters (angle, amplitude, and width) on the mechanical characteristics (radial strength and radial recoil) using finite element analysis. The width of the strut was found to be the primary determinant of the stent structure's properties. Consequently, the angle and width were found to have the least effect on altering the stent's mechanical properties. After performing the parametric analysis, optimal design factors were selected to design the full-length DA auxetic stent. The mechanical characteristics of the DA auxetic stent were assessed and compared in a case study with the Cypher™ commercial stent. The radial strength of DA auxetic stent was found to be 7.26 N/mm, which is more than double the Cypher™ commercial stent's radial strength. Additionally, the proposed stent possesses reduced radial recoil property and completely eliminates the stent foreshortening issue, which shows the superior mechanical properties of the proposed auxetic stent and its potential as a promising candidate for future stent designs.

Additive manufacturing of vascular stents

With the advancement of additive manufacturing (AM), customized vascular stents can now be fabricated to fit the curvatures and sizes of a narrowed or blocked blood vessel, thereby reducing the possibility of thrombosis and restenosis. More importantly, AM enables the design and fabrication of complex and functional stent unit cells that would otherwise be impossible to realize with conventional manufacturing techniques. Additionally, AM makes fast design iterations possible while also shortening the development time of vascular stents. This has led to the emergence of a new treatment paradigm in which custom and on-demand-fabricated stents will be used for just-in-time treatments. This review is focused on the recent advances in AM vascular stents aimed at meeting the mechanical and biological requirements. First, the biomaterials suitable for AM vascular stents are listed and briefly described. Second, we review the AM technologies that have been so far used to fabricate vascular stents as well as the performances they have achieved. Subsequently, the design criteria for the clinical application of AM vascular stents are discussed considering the currently encountered limitations in materials and AM techniques. Finally, the remaining challenges are highlighted and some future research directions are proposed to realize clinically-viable AM vascular stents. STATEMENT OF SIGNIFICANCE: Vascular stents have been widely used for the treatment of vascular disease. The recent progress in additive manufacturing (AM) has provided unprecedented opportunities for revolutionizing traditional vascular stents. In this manuscript, we review the applications of AM to the design and fabrication of vascular stents. This is an interdisciplinary subject area that has not been previously covered in the published review articles. Our objective is to not only present the state-of-the-art of AM biomaterials and technologies but to also critically assess the limitations and challenges that need to be overcome to speed up the clinical adoption of AM vascular stents with both anatomical superiority and mechanical and biological functionalities that exceed those of the currently available mass-produced devices.

Understanding Atherosclerosis Pathophysiology: Can Additive Manufacturing Be Helpful?

Atherosclerosis is one of the leading causes of death worldwide. Although this subject arouses much interest, there are limitations associated with the biomechanical investigation done in atherosclerotic tissues, namely the unstandardized tests for the mechanical characterization of these tissues and the inherent non-consensual results obtained. The variability of tests and typologies of samples hampers direct comparisons between results and hinders the complete understanding of the pathologic process involved in atherosclerosis development and progression. Therefore, a consensual and definitive evaluation of the mechanical properties of healthy and atherosclerotic blood vessels would allow the production of physical biomodels that could be used for surgeons' training and personalized surgical planning. Additive manufacturing (AM), commonly known as 3D printing, has attracted significant attention due to the potential to fabricate biomodels rapidly. However, the existing literature regarding 3D-printed atherosclerotic vascular models is still very limited. Consequently, this review intends to present the atherosclerosis disease and the consequences of this pathology, discuss the mechanical characterization of atherosclerotic vessels/plaques, and introduce AM as a potential strategy to increase the understanding of atherosclerosis treatment and pathophysiology.