3D printed grafts with gradient structures for organized vascular regeneration

Synthetic vascular grafts suitable for small-diameter arteries(<6 mm) are in great need.However,there are still no commercially available small-diameter vascular grafts(SDVGs) in clinical practice due to thrombosis and stenosis after in vivo implantation.When designing SDVGs,many studies emphasized reendothelization but ignored the importance of reconstruction of the smooth muscle layer(SML).To facilitate rapid SML regeneration,a high-resolution 3D printing method was used to create a novel bilayer SDVG with structures and mechanical properties mimicking natural arteries.Bioinspired by the collagen alignment of SML,the inner layer of the grafts had larger pore sizes and high porosity to accelerate the infiltration of cells and their circumferential alignment,which could facilitate SML reconstruction for compliance restoration and spontaneous endothelialization.The outer layer was designed to induce fibroblast recruitment by low porosity and minor pore size and provide SDVG with sufficient mechanical strength.One month after implantation,the arteries regenerated by 3D-printed grafts exhibited better pulsatility than electrospun grafts,with a compliance(8.9%) approaching that of natural arteries(11.36%) and significantly higher than that of electrospun ones(1.9%).The 3D-printed vascular demonstrated a three-layer structure more closely resembling natural arteries while electrospun grafts showed incomplete endothelium and immature SML.Our study shows the importance of SML reconstruction during vascular graft regeneration and provides an effective strategy to reconstruct blood vessels through 3D-printed structures rapidly.

Advances in the differentiation of pluripotent stem cells into vascular cells

Blood vessels constitute a closed pipe system distributed throughout the body,transporting blood from the heart to other organs and delivering metabolic waste products back to the lungs and kidneys.Changes in blood vessels are related to many disorders like stroke,myocardial infarction,aneurysm,and diabetes,which are important causes of death worldwide.Translational research for new appro-aches to disease modeling and effective treatment is needed due to the huge socio-economic burden on healthcare systems.Although mice or rats have been widely used,applying data from animal studies to human-specific vascular physiology and pathology is difficult.The rise of induced pluripotent stem cells(iPSCs)provides a reliable in vitro resource for disease modeling,regenerative medicine,and drug discovery because they carry all human genetic information and have the ability to directionally differentiate into any type of human cells.This review summarizes the latest progress from the establishment of iPSCs,the strategies for differentiating iPSCs into vascular cells,and the in vivo trans-plantation of these vascular derivatives.It also introduces the application of these technologies in disease modeling,drug screening,and regenerative medicine.Additionally,the application of high-tech tools,such as omics analysis and high-throughput sequencing,in this field is reviewed.

Animal models of vascularized nerve grafts:a systematic review

The aim of this review is to present and compare the various animal models of vascularized nerve grafts described in the literature as well as to summarize preclinical evidence for superior functional results compared to non-vascularized free nerve grafts. We also will present the state of the art on prefabricated vascularized nerve grafts. A systematic literature review on vascularized nerve graft models was conducted via the retrieval with the Pub Med database on March 30, 2019. Data on the animal, nerve, and vascularization model, the recipient bed, the evaluation time points and methods, and the results of the study results were extracted and analyzed from selected articles. The rat sciatic nerve was the most popular model for vascularized nerve grafts, followed by the rabbit;however, rabbit models allow for longer nerve grafts, which are suitable for translational evaluation, and produced more cautious results on the superiority of vascularized nerve grafts. Compared to free nerve grafts, vascularized nerve grafts have better early but similar long-term results, especially in an avascular bed. There are few studies on avascular receiving beds and prefabricated nerve grafts. The clinical translation potential of available animal models is limited, and current experimental knowledge cannot fully support that the differences between vascularized nerve grafts and free nerve grafts yield a clinical advantage that justifies the complexity of the procedure.

Current Strategies of Surface Modifications to Polyurethane Biomaterials for Vascular Grafts

As the number of patients suffering from cardiovascular diseases and peripheral vascular diseases rises,the constraints of autologous transplantation remain unavoidable.As a result,artificial vascular grafts must be developed.Adhesion of proteins,platelets and bacteria on implants can result in stenosis,thrombus formation,and postoperative infection,which can be fatal for an implantation.Polyurethane,as a commonly used biomaterial,has been modified in various ways to deal with the adhesions of proteins,platelets,and bacteria and to stimulate endothelium adhesion.In this review,we briefly summarize the mechanisms behind adhesions,overview the current strategies of surface modifications of polyurethane biomaterials used in vascular grafts,and highlight the challenges that need to be addressed in future studies,aiming to gain a more profound understanding of how to develop artificial polyurethane vascular grafts with an enhanced implantation success rate and reduced side effect.

Appearance of aseptic vascular grafts after endovascular aortic repair on[(18)F]fluorodeoxyglucose positron emission tomography/computed tomography

BACKGROUND Diagnosis of prosthetic vascular graft infection with[(18)F]fluorodeoxyglucose positron emission tomography/computed tomography(18F-FDG PET/CT)allows for early detection of functional changes associated with infection,based on increased glucose utilization by activated macrophages and granulocytes.Aseptic vascular grafts,like all foreign bodies,can stimulate an inflammatory response,which can present as increased activity on 18F-FDG PET/CT.Consequently,distinguishing aseptic inflammation from graft infection,though important,can be difficult.In the case of endovascular aneurysm repair(EVAR),a minimally invasive procedure involving the transfemoral insertion of an endoprosthetic stent graft,the normal postoperative appearance of these grafts on 18F-FDG PET/CT can vary over time,potentially confounding study interpretation.AIM To investigate the visual,semiquantitative,and temporal characteristics of aseptic vascular grafts in patients status post EVAR.METHODS In this observational retrospective cohort study,patients with history of EVAR who underwent 18F-FDG PET/CT for indications other than infection were identified retrospectively.All patients were asymptomatic for graft infection-no abdominal pain,fever of unknown origin,sepsis,or leukocytosis-at the time of imaging and for≥2 mo after each PET/CT.Imaging studies such as CT for each patient were also reviewed,and any patients with suspected or confirmed vascular graft infection were excluded.One hundred two scans performed on 43 patients(34 males;9 females;age=77±8 years at the time of the final PET/CT)were retrospectively reviewed.All 43 patients had an abdominal aortic(AA)vascular graft,40 patients had a right iliac(RI)limb graft,and 41 patients had a left iliac(LI)limb graft.Twentytwo patients had 1 PET/CT and 21 patients had from 2 to 9 PET/CTs.Grafts were imaged between 2 mo to 168 mo(about 14 years)post placement.Eight grafts were imaged within 6 mo of placement,including three that were imaged within three months of placement.The mean interval between graft placement and PET/CT for all 102 scans was 51±39 mo.PET/CT data was reconstructed with region-of-interest analysis of proximal,mid and distal portions of the grafts and background ascending aorta.Maximum standardized uptake value(SUVmax)was recorded for each region.SUVmax-to-background uptake ratios(URs)were calculated.Visual assessment was performed using a 2-pattern grading scale:Diffuse(homogeneous uptake less than liver uptake)and focal(one or more areas of focal uptake in any part of the graft).Statistical analysis was performed.RESULTS In total,there were 306 AA grafts,285 LI grafts,282 RI grafts,and 306 ascending aorta background SUVmax measurements.For all 102 scans,mean SUVmax values for AA grafts were 2.8-3.0 along proximal,mid,and distal segments.Mean SUVmax values for LI grafts and RI grafts were 2.7-2.8.Mean SUVmax values for background were 2.5±0.5.Mean URs were 1.1-1.2.Visual analysis of the scans reflected results of quantitative analysis.On visual inspection,98%revealed diffuse,homogeneous 18F-FDG uptake less than liver.Graft URs and visual pattern categories were significantly associated for AA graft URs(F-ratio=21.5,P<0.001),LI graft URs(F-ratio=20.4,P<0.001),and RI graft URs(F-ratio=30.4,P<0.001).Thus,visual patterns of 18F-FDG uptake corresponded statistically significantly to semiquantitative URs.The age of grafts showing focal patterns was greater than grafts showing diffuse patterns,87±89 vs 50±37 mo,respectively(P=0.02).URs were significantly associated with graft age for AA grafts(r=0.19,P=0.001).URs were also significantly associated with graft age for LI grafts(r=0.25,P<0.0001),and RI grafts(r=0.31,P<0.001).Quartiles of similar numbers of graft(n=25-27)grouped by graft age indicated that URs were significantly higher for 4th quartile vs 2nd quartile URs(F-ratio=19.5,P<0.001).When evaluating URs,graft SUVmax values within 10%-20%of the ascending aorta SUVmax is evident in aseptic grafts,except for grafts in the oldest quartiles.In this study,grafts in the oldest quartiles(>7 years post EVAR)showed SUVmax up to 30%higher than the ascending aorta SUVmax.CONCLUSION Characteristics of an aseptic vascular stent graft in the aorta and iliac vessels on 18F-FDG PET/CT include graft SUVmax values within 10%-20%of the ascending aorta background SUVmax.The SUVmax of older aseptic grafts can be as much as 30%above background.The visual uptake pattern of diffuse,homogeneous uptake less than liver was seen in 98%of aseptic vascular grafts,making this pattern particularly reassuring for clinicians.

The role of vascularization in nerve regeneration of nerve graft

Vascularization is an important factor in nerve graft survival and function. The specific molecular regulations and patterns of angiogenesis following peripheral nerve injury are in a broad complex of pathways. This review aims to summarize current knowledge on the role of vascularization in nerve regeneration, including the key regulation molecules, and mechanisms and patterns of revascularization after nerve injury. Angiogenesis, the maturation of pre-existing vessels into new areas, is stimulated through angiogenic factors such as vascular endothelial growth factor and precedes the repair of damaged nerves. Vascular endothelial growth factor administration to nerves has demonstrated to increase revascularization after injury in basic science research. In the clinical setting, vascularized nerve grafts could be used in the reconstruction of large segmental peripheral nerve injuries. Vascularized nerve grafts are postulated to accelerate revascularization and enhance nerve regeneration by providing an optimal nutritional environment, especially in scarred beds, and decrease fibroblast infiltration. This could improve functional recovery after nerve grafting, however, conclusive evidence of the superiority of vascularized nerve grafts is lacking in human studies. A well-designed randomized controlled trial comparing vascularized nerve grafts to non-vascularized nerve grafts involving patients with similar injuries, nerve graft repair and follow-up times is necessary to demonstrate the efficacy of vascularized nerve grafts. Due to technical challenges, composite transfer of a nerve graft along with its adipose tissue has been proposed to provide a healthy tissue bed. Basic science research has shown that a vascularized fascial flap containing adipose tissue and a vascular bundle improves revascularization through excreted angiogenic factors, provided by the stem cells in the adipose tissue as well as by the blood supply and environmental support. While it was previously believed that revascularization occurred from both nerve ends, recent studies propose that revascularization occurs primarily from the proximal nerve coaptation. Fascial flaps or vascularized nerve grafts have limited applicability and future directions could lead towards off-the-shelf alternatives to autografting, such as biodegradable nerve scaffolds which include capillary-like networks to enable vascularization and avoid graft necrosis and ischemia.

Proliferation of endothelial cell on polytetrafluoroethylene vascular graft materials carried VEGF gene plasmid

Objective： To investigate whether vascular endothelial growth factor （VEGF） gene plasmid carried by polytetrafluoroethylene （PTFE） vascular graft materials could transfect endothelial cells （ECs） and promote their growth. Methods： PTFE vascular graft materials carried with pCDI-hVEGF121, pCDI or pEGFP were incubated in Tris-buffer solution and the values of optical density of 260 nm at different time were plotted, then the DNA controlled release curve was made. ECs derived from human umbilical vein were seeded on the pCDI-hVEGF121/pCDI/pEGFP-PTFE materials or tissue culture plates, ECs numbers were counted and VEGF protein concentrations at different time were measured by enzyme-linked immunoadsorbent assay method. Green fluorescent protein （GFP） expression in ECs on pEGFP-PTFE materials was examined with fluorescence mi- croscopy. Results： The controlled release curve showed that the gene released from PTFE materials was rapid within 8 h, then slowed down and that the gene released continuously even after 72 h. At 24, 72 and 120 h, ECs number and proliferation rate of pCDI-hVEGFI21-PTFE materials were higher than those ofpCDI or pEGFP-PTFE materials （P〈0.05）. VEGF protein concentration of pCDI-hVEGF121-PTFE materials was higher than that of pC DI or pEGFP-PTFE materials at 6, 24, 72 and 120 h （P〈0.01）. GFP expression in ECs on the pEGFP-PTFE materials could be detected by fluorescence microscopy. Conclusion： PTFE graft can be used as a carrier of VEGF gene plasmid, VEGF gene carried by PTFE can transfect ECs and promote ECs growth.

Structural design and mechanical performance of composite vascular grafts

This study reviews the state of the art in structural design and the corresponding mechanical behaviours of composite vascular grafts. We critically analyse surface and matrix designs composed of layered, embedded, and hybrid structures along the radial and longitudinal directions;materials and manufacturing techniques, such as tissue engineering and the use of textiles or their combinations;and the corresponding mechanical behaviours of composite vascular grafts in terms of their physical–mechanical properties, especially their stress–strain relationships and elastic recovery. The role of computational studies is discussed with respect to optimizing the geometrics designs and the corresponding mechanical behaviours to satisfy specialized applications, such as those for the aorta and its subparts. Natural and synthetic endothelial materials yield improvements in the mechanical and biological compliance of composite graft surfaces with host arteries. Moreover,the diameter, wall thickness, stiffness, compliance, tensile strength, elasticity, and burst strength of the graft matrix are determined depending on the application and the patient. For composite vascular grafts, hybrid architectures are recommended featuring multiple layers, dimensions, and materials to achieve the desired optimal flexibility and function for complying with user-specific requirements. Rapidly emerging artificial intelligence and big data techniques for diagnostics and the threedimensional(3D) manufacturing of vascular grafts will likely yield highly compliant, subject-specific, long-lasting, and economical vascular grafts in the near-future.

Salvage of vascular graft infections via vacuum sealing drainage and rectus femoris muscle flap transposition: A case report

BACKGROUND The management of vascular graft infections continues to be a significant challenge in a clinical situation.The aim of this report is to illustrate the novel vacuum sealing drainage(VSD)technique and rectus femoris muscle flap transposition for vascular graft infections,and to evaluate the prospective of future testing of this surgical procedure.CASE SUMMARY We report the case of a 32-year-old male patient,who presented a severe infected groin wound with biological vascular graft Acinetobacter baumannii infection resulting in extensive graft exposure.Using the VSD and muscle flap transposition,the groin wound and vascular graft infection were finally treated successfully.CONCLUSION Our case report highlights that VSD technique and rectus femoris muscle flap transposition could be considered in patients presenting with a severe infected groin wound with biological vascular graft Acinetobacter baumannii infection resulting in extensive graft exposure,especially in consideration of treatable conditions.

Modelling Mechanical Properties in Native and Biomimetically Formed Vascular Grafts

The paper presents a detailed analysis of experimental data in order to characterize the elastic properties of arteries.Such analysis would provide a good basis for evaluation of biomimetic vascular grafts.Since the latter needs to exhibit similar properties of native tissue,it is important to accurately characterize the biomimetic sample in a large range of applied stresses. The stress-strain properties vary according to the specific pathology(e.g.arteriosclerosis,aneurism)and the tissue graft must be chosen correctly.Two models are proposed in this paper on the stress-strain characteristics.An extension for frequency-domain analysis is provided for one of the models.The comparison between vascular grafts and native tissue for carotid and thoracic arteries in pigs are in good agreement with results from literature.The proposed experimental method offers suitable parameters for identifying models which characterize both elasticity and stiffness properties of the analyzed tissues(stress-strain).The proposed models show good performance in characterizing the intrinsic material properties.

Automatic Formation Techniques of Woven Conical Vascular Graft

Conical vascular tubes are of strong demand owing to their formed shape and excellent characters to mimic human blood vessels. In this study,the automatic shuttle loom and computer aided design( CAD) system were customized to prepare a conical vascular graft. Meanwhile, the weaving principle of a conical vascular graft was identified in terms of the lift-drop front rest,and the geometrical relations were established among the cloth fell,front rest and back rest. Also,the change of weft density from the liftdrop motion of the front rest was analyzed,and a strategy was established to compensate the offset of weft density by changing the taken-up length. Afterwards,the proposed weaving principles were demonstrated by weaving a conical vascular graft on the customized shuttle loom.

Longitudinal Mechanical Properties of Small-Diameter Polyurethane Vascular Graft Reinforced by Tubular Knitted Fabric

The vascular graft with 4 mm diameter was prepared by casting one layer of polyurethane (PU) film onto the knitting tubular fabric as the reinforced support. The effects of different PU content and wall thickness on the longitudinal mechanical properties of vascular graft were investigated. The breaking elongation, breaking force, initial modulus and breaking work were studied. The results showed that the longitudinal mechanical properties of vascular graft were enhanced as the content of polyurethane increased, which resulted from the combination of PU excellent elasticity and fabric preferable strength.

Mechanical Properties of Small-diameter Superfine Silk Powder/Polyurethane Vascular Graft Reinforced by Tubular Knitted Fabric

In this paper,a kind of composite microtube,which is made from superfine silk powder and polyurethane,reinforced by polyster and spandex tubular fabrics,was examined.The cross-section of composite microtubes were microporous,and micropores were uniform distributed,the inner surface was relatively smooth.The results showed that the wall thickness of composite microtubes increased,which led to the strength,the breaking work and the initial modulus incresead;that the spandex content increased brought about the initial modulus and the breaking work decreased,but the breaking extension and the breaking load were firstly increased and then decreased;and all the mechanical properties decreased as the SFSP content increased.

Study of a Novel Small Caliber Vascular Graft in a Canine Model with Optical and Scanning Electron Microscopy

A novel biological small-diameter vascular graft was evaluated in a canine model. 3 cm long segments with 4 mm I.D. were implanted end-to-end in the carotid position of 12 dogs for 6 months. Color Doppler sonography was performed at the first week post-operation, and angiography was then administered to 9 grafts at 4th week, 12th week and 24th week respectively to monitor the graft pantency and blood flow characteristics. Vascular samples containing the grafts were collected at 1st week, 8th week, 12th week and 24th week after implantation. Morphological changes of the grafts were observed by optical and scanning electron microscopic (SEM) studies and compared with that of the original prosthesis and the normal host vessel. All grafts were patent throughout the experiment except one graft. Histopathology and SEM demonstrated both a nearly complete inner capsule of varied thickness lining the graft luminal surface and connective tissue adventitia formation at one-week post-operation. The neointima became confluent at 8 weeks and then compact but had no signs of hyperplasia up to 12 weeks; meanwhile on the neointimal surface newly grown endothelial-like cells were migrating from the stoma to the middle portion. The grafts also illustrated endothelialization in many “islands” in the mid-segment luminal surface of the grafts. In addition, the closer distance the cells towards the stoma were, the more morphological similarity the cells with the normal endothelial were. Taken together, the biological vascular graft remained patent for 24 weeks as a carotid prosthesis, characterized by the early and complete neointima formation plus endothelialization starting before 12 weeks post grafting. Therefore, the graft seems suitable for reconstruction of vascular lesions in dogs. Further studies may be carried out to extend the graft application for the clinical use.

Construction and evaluation of co-electrospun poly (butylene succinate)/gelatin materials as potential vascular grafts

In this study,a series of poly(butylene succinate)(PBSU)/gelatin composites were prepared by electrospinning.The morphology,physicochemical analysis,biomechanical properties,biocompatibility,and biodegradability of the materials were evaluated.The results showed that the ultimate tensile stress of the vascular PBSU/gelatin grafts at(95/5),(90/10),(85/15),and(80/20)was(4.17±0.54)MPa,(3.81±0.44)MPa,2.94±0.69 MPa and 2.11±0.72 MPa respectively,and the burst pressure was(282.7±22.3)kPa,(295.3±3.9)kPa,(306.8±13.9)kPa and(307.6±9.0)kPa respectively,which met the requirements of tissue-engineered blood vessels.Furthermore,the addition of gelatin improved the hydrophilicity and degradation properties of PBSU,thus enhancing cell adhesion and promoting the inward growth of vascular smooth muscle cells.In summary,the research in this paper provides a useful reference for the preparation and optimization of vascular scaffolds.

Bilayer nicorandil-loaded small-diameter vascular grafts improve endothelial cell function via PI3K/AKT/eNOS pathway

For the surgical treatment of cardiovascular disease(CVD),there is a clear and unmet need in developing small-diameter(diameter<6 mm)vascular grafts.In our previous work,sulfated silk fibroin(SF)was successfully fabricated as a potential candidate for preparing vascular grafts due to the great cytocompatibility and hemocompatibility.However,vascular graft with single layer is difficult to adapt to the complex internal environment.In this work,polycaprolactone(PCL)and sulfated SF were used to fabricate bilayer vascular graft(BLVG)to mimic the structure of natural blood vessels.To enhance the biological activity of BLVG,nicorandil(NIC),an FDA-approved drug with multi-bioactivity,was loaded in the BLVG to fabricate NIC-loaded BLVG.The morphology,chemical composition and mechanical properties of NIC-loaded BLVG were assessed.The results showed that the bilayer structure of NIC-loaded BLVG endowed the graft with a biphasic drug release behavior.The in vitro studies indicated that NIC-loaded BLVG could significantly increase the proliferation,migration and antioxidation capability of endothelial cells(ECs).Moreover,we found that the potential biological mechanism was the activation of PI3K/AKT/eNOS signaling pathway.Overall,the results effectively demonstrated that NIC-loaded BLVG had a promising in vitro performance as a functional small-diameter vascular graft.

Treatment of Scaphoid Nonunion: Pedicled Vascularized Bone Graft vs. Traditional Bone Graft

The clinical results of the application of pedicled vascularized bone graft （VBG） from Lister＇s tubercle vs. traditional bone graft （TBG） were evaluated and compared. Thirteen cases of symptomatic scaphoid nonunion were treated between January 2011 and December 2012, including 7 cases subject to VBG and the rest 6 cases to TBG, respectively. Outcomes were assessed by modified Mayo wrist score system. All cases were followed up for an average period of 3.5 months after opera- tion. The results showed that total scores in VBG group were 86.4i9.4 after operation with excellent result in 4 cases, good in 2 and acceptable in one, and those in TBG group were 71.7±9.3 after operation with good result in 2 cases, acceptable in 3 and disappointing in one. Total score of wrist function was significantly improved in VBG group as compared with TBG group （P〈0.05）. Our study suggests that VBG method is more effective for treating scaphoid nonunion than TBG method.

TREATMENT OF ISCHEMIC NECROSIS OF FEMORAL HEAD BY THE FREE TRANSFERRING FIBULAR BONE GRAFT WITH VASCULAR PEDICLE IN ADULTS: A REPORT ON 95 CASES

cases (97 hips) with avascular necrosis of femoral head caused by variors factors treated by the free transferring fibular graft with vascular pedicle in the Second Teaching Hospital of Xi'an Medical University are reported. All patients have ben followed up for 2 to 11 years. Excellent and good rate of operative results was 86. 6%. A long observation indicated that this procedure was superior to the other operations for the osteonecrosis of femoral head. Successful interim and final operative results can warrant its continued use in management of this kind of patients.

Immediate post-operative complications(I):Post-operative bleeding;vascular origin:Thrombosis pancreatitis

Simultaneous pancreas-kidney transplantation is the treatment of choice forinsulin-dependent diabetes that associates end-stage diabetic nephropathy, sinceit achieves not only a clear improvement in the quality of life, but also provides along-term survival advantage over isolated kidney transplant. However, pancreastransplantation still has the highest rate of surgical complications among organtransplants. More than 70% of early graft losses are attributed to technical failures,that is, to a non-immunological cause. The so-called technical failures includegraft thrombosis, bleeding, infection, pancreatitis, anastomotic leak and pancreaticfistula. Pancreatic graft thrombosis leads these technical complications as the mostfrequent cause of early graft loss. Currently most recipients receive postoperativeanticoagulation with the aim of reducing the rate of thrombosis. Hemoperitoneumin the early postoperative period is a frequent cause of relaparotomy, but it is notusually associated with graft loss. The incidence of hemoperitoneum is clearlyrelated to the use of anticoagulation in the postoperative period. Post-transplantpancreatitis is another cause of early postoperative complications, less frequentthan the previous. In this review, we analyze the most common surgicalcomplications that determine pancreatic graft losses.