Histological Reactions and the In Vivo Patency Rates of Small Silk Vascular Grafts in a Canine Model

Silk fibroin-based scaffolds for tissue engineering

Silk fibroin is an important natural fibrous protein with excellent prospects for tissue engineering applications. With profound studies in recent years, its potential in tissue repair has been developed. A growing body of literature has investigated various fabricating methods of silk fibroin and their application in tissue repair. The purpose of this paper is to trace the latest developments of SF-based scaffolds for tissue engineering. In this review, we first presented the primary and secondary structures of silk fibroin. The processing methods of SF scaffolds were then summarized. Lastly, we examined the contribution of new studies applying SF as scaffolds in tissue regeneration applications. Overall, this review showed the latest progress in the fabrication and utilization of silk fibroin-based scaffolds.

In-vivo evaluation of silk fibroin small-diameter vascular grafts: state of art of preclinical studies and animal models

Autologous vein and artery remains the first choice for vascular grafting procedures in small-diameter vessels such as coronary and lower limb districts. Unfortunately, these vessels are often found to be unsuitable in atherosclerotic patients due to the presence of calcifications or to insufficient size. Synthetic grafts composed of materials such as expanded polytetrafluoroethylene (ePTFE) are frequently employed as second choice, because of their widespread availability and success in the reconstruction of larger arteries. However, ePTFE grafts with small diameter are plagued by poor patency rates due to surface thrombogenicity and intimal hyperplasia, caused by the bioinertness of the synthetic material and aggravated by low flow conditions. Several bioresorbable and biodegradable polymers have been developed and tested to exploit such issues for their potential stimulation to endothelialization and cell infiltration. Among these, silk fibroin (SF) has shown promising pre-clinical results as material for small-diameter vascular grafts (SDVGs) because of its favorable mechanical and biological properties. A putative advantage in graft infection in comparison with synthetic materials is plausible, although it remains to be demonstrated. Our literature review will focus on the performance of SF-SDVGs in vivo, as evaluated by studies performing vascular anastomosis and interposition procedures, within small and large animal models and different arterial districts. Efficiency under conditions that more accurately mime the human body will provide encouraging evidence towards future clinical applications.

Improving Biocompatibility of Polyester Fabrics through Polyurethane/Gelatin Complex Coating for Potential Vascular Application

Medical apparatus and instruments, such as vascular grafts, are first exposed to blood when they are implanted. Therefore, blood compatibility is considered to be the critical issue when constructing a vascular graft. In this regard, the coating method is verified to be an effective and simple approach to improve the blood compatibility as well as prevent the grafts from blood leakage. In this study, polyester fabric is chosen as the substrate to provide excellent mechanical properties while a coating layer of polyurethane is introduced to prevent the blood leakage. Furthermore, gelatin is coated on the substrate to mimic the native extracellular matrix together with the improvement of biocompatibility. XPS and FTIR analysis are performed for elemental and group analysis to determine the successful coating of polyurethane and gelatin on the polyester fabrics. In terms of blood compatibility, hemolysis and platelet adhesion are measured to investigate the anticoagulation performance. In vitro cell experiments also indicate that endothelial cells show good proliferation and morphology on the polyester fabric modified with such coating layers. Taken together, such polyester fabric coated with polyurethane and gelatin layers would have a promising potential in constructing vascular grafts with expected blood compatibility and biocompatibility without destroying the basic mechanical requirements for vascular applications.

Bioengineering silk into blood vessels

The rising incidence of cardiovascular disease has increased the demand for small diameter (<6 mm) synthetic vascular grafts for use in bypass surgery. Clinically available synthetic grafts (polyethylene terephthalate and expanded polytetrafluorethylene) are incredibly strong, but also highly hydrophobic and inelastic, leading to high rates of failure when used for small diameter bypass. The poor clinical outcomes of commercial synthetic grafts in this setting have driven significant research in search of new materials that retain favourable mechanical properties but offer improved biocompatibility. Over the last several decades, silk fibroin derived from Bombyx mori silkworms has emerged as a promising biomaterial for use in vascular applications. Progress has been driven by advances in silk manufacturing practices which have allowed unprecedented control over silk strength, architecture, and the ensuing biological response. Silk can now be manufactured to mimic the mechanical properties of native arteries, rapidly recover the native endothelial cell layer lining vessels, and direct positive vascular remodelling through the regulation of local inflammatory responses. This review summarises the advances in silk purification, processing and functionalisation which have allowed the production of robust vascular grafts with promise for future clinical application.

Silk biomaterials for vascular tissue engineering applications

Vascular tissue engineering is a rapidly growing field of regenerative medicine, which strives to find innovative solutions for vascular reconstruction. Considering the limited success of synthetic grafts, research impetus in the field is now shifted towards finding biologically active vascular substitutes bestowing in situ growth potential. In this regard, silk biomaterials have shown remarkable potential owing to their favorable inherent biological and mechanical properties. This review provides a comprehensive overview of the progressive development of silk-based small diameter (<6 mm) tissue-engineered vascular grafts (TEVGs), emphasizing their pre-clinical implications. Herein, we first discuss the molecular structure of various mulberry and non-mulberry silkworm silk and identify their favorable properties at the onset of vascular regeneration. The emergence of various state-of-the-art fabrication methodologies for the advancement of silk TEVGs is rationally appraised in terms of their in vivo performance considering the following parameters: ease of handling, long-term patency, resistance to acute thrombosis, stenosis and aneurysm formation, immune reaction, neo-tissue formation, and overall remodeling. Finally, we provide an update on the pre-clinical status of silk-based TEVGs, followed by current challenges and future prospects. STATEMENT OF SIGNIFICANCE: Limited availability of healthy autologous blood vessels to replace their diseased counterpart is concerning and demands other artificial substitutes. Currently available synthetic grafts are not suitable for small diameter blood vessels owing to frequent blockage. Tissue-engineered biological grafts tend to integrate well with the native tissue via remodeling and have lately witnessed remarkable success. Silk fibroin is a natural biomaterial, which has long been used as medical sutures. This review aims to identify several favorable properties of silk enabling vascular regeneration. Furthermore, various methodologies to fabricate tubular grafts are discussed and highlight their performance in animal models. An overview of our understanding to rationally improve the biological activity fostering the clinical success of silk-based grafts is finally discussed.

Evaluation of small-diameter silk vascular grafts implanted in dogs

Objectives

Methods

Results

Conclusions

Silk fibroin vascular graft: a promising tissue-engineered scaffold material for abdominal venous system replacement

No alternative tissue-engineered vascular grafts for the abdominal venous system are reported. The present study focused on the development of new tissue-engineered vascular graft using a silk-based scaffold material for abdominal venous system replacement. A rat vein, the inferior vena cava, was replaced by a silk fibroin (SF, a biocompatible natural insoluble protein present in silk thread), tissue-engineered vascular graft (10 mm long, 3 mm diameter, n = 19, SF group). The 1 and 4 -week patency rates and histologic reactions were compared with those of expanded polytetrafluoroethylene vascular grafts (n = 10, ePTFE group). The patency rate at 1 and 4 weeks after replacement in the SF group was 100.0% and 94.7%, and that in the ePTFE group was 100.0% and 80.0%, respectively. There was no significant difference between groups (p = 0.36). Unlike the ePTFE graft, CD31-positive endothelial cells covered the whole luminal surface of the SF vascular graft at 4 weeks, indicating better endothelialization. SF vascular grafts may be a promising tissue-engineered scaffold material for abdominal venous system replacement.

Insight on the endothelialization of small silk-based tissue-engineered vascular grafts

Along with an increased incidence of cardiovascular diseases, there is a strong need for small-diameter vascular grafts. Silk has been investigated as a biomaterial to develop such grafts thanks to different processing options. Endothelialization was shown to be extremely important to ensure graft patency and there is ongoing research on the development and behavior of endothelial cells on vascular tissue-engineered scaffolds. This article reviews the endothelialization of silk-based scaffolds processed throughout the years as silk non-woven nets, films, gel spun, electrospun, or woven scaffolds. Encouraging results were reported with these scaffolds both in vitro and in vivo when implanted in small- to middle-sized animals. The use of coatings and heparin or sulfur to enhance, respectively, cell adhesion and scaffold hemocompatibility is further presented. Bioreactors also showed their interest to improve cell adhesion and thus promoting in vitro pre-endothelialization of grafts even though they are still not systematically used. Finally, the importance of the animal models used to study the right mechanism of endothelialization is discussed.

Development of Small-diameter Polyester Vascular Grafts Coated with Silk Fibroin Sponge

In recent years, the demand for functional small-diameter (< 6 mm) artificial vascular grafts has greatly increased due to an increase in the number of patients with vascular heart disease. However, currently, there are no available commercial small-diameter grafts. The objective of this research was to develop a porous silk fibroin (SF)-coated poly(ethylene terephthalate) (PET) graft with a diameter < 6 mm. The graft was compared with a gelatin-coated PET graft because the latter PET graft with a diameter ~ 6 mm was widely used as a commercial vascular graft. Initially, porous SF was prepared using Glyc as the porogen [termed SF(Glyc)] and the PET grafts were prepared through the double-Raschel knitting method. Subsequently, the degradation of the SF coating was monitored using protease XIV in vitro and was compared with that observed in gelatin-coated PET grafts. Finally, these grafts were also implanted into rats for an in vivo comparison. In degradation experiments, after 7 days, the SF was clearly digested by protease XIV, but the gelatin on the graft was still remained at the outer surface. In implantation experiments in rats, the SF(Glyc)-coated PET graft was rapidly degraded in vivo and remodeling to self-tissues was promoted compared with the gelatin-coated PET graft. Thrombus formation and intimal hyperplasia were observed in the gelatin-coated PET graft; however, such side reactions were not observed in the SF(Glyc)-coated PET graft. Thus, the porous SF(Glyc)-coated PET graft with a small diameter < 6 mm may be useful as a commercial vascular graft.