Small calibre biosynthetic bacterial cellulose blood vessels: 13-months patency in a sheep model.

OBJECTIVES: Many patients in need of bypass surgery lack graft material and current synthetic alternatives have poor performance. A 4 mm vascular graft composed of bacterial cellulose (BC) was developed and tested in pilot study in a large animal model. DESIGN: BC is a biopolymer made by the bacteria acetobacter xylinum. BC grafts (n = 16) with 4 cm length and 4 mm internal diameter were implanted bilaterally in the carotid arteries of eight sheep. No long-term antithrombotic therapy was administered. Patency was assessed with ultrasound. Histology, immunohistochemistry, and electron microscopy were performed after explantation. RESULTS: Fifty percent of the grafts occluded within two weeks. One animal died with patent grafts after 14 days. In the three remaining animals 5/6 grafts were patent after nine months. Two animals were followed 13 months after implantation with 3/4 grafts patent at explantation. All patent grafts had confluent endothelial-like cells. CONCLUSIONS: Biosynthetic small calibre vascular grafts made from BC can be patent for up to 13 months in sheep carotid arteries. BC is a potential material for small calibre grafts but patency in animal models needs to be improved before clinical studies can be planned.

Modification of nanocellulose with a xyloglucan-RGD conjugate enhances adhesion and proliferation of endothelial cells: implications for tissue engineering.

This paper describes a novel method for introducing the RGD cell adhesion peptide to enhance cell adhesion onto bacterial cellulose (BC). BC and cotton linters as reference were modified with xyloglucan (XG) and xyloglugan bearing a GRGDS pentapeptide. The adsorptions followed Langmuir adsorption behavior, where both XGs probably decorate the cellulose surfaces as a monolayer. The adsorption maximum of the XGs reached around 180 mg/g on BC and only about three times as much on cotton linters. The adsorption was verified with colorimetric methods. The specific surface area of BC measured with XG and XG-GRGDS was about 200 m (2)/g and was almost three times less for cotton linters, 60 m (2)/g. The difference in the amounts of XGs adsorbed might be explained by the swollen network of bacterial cellulose and a more exposed and accessible bulk as compared to cotton linters. The nanocellulose material was modified homogeneously throughout the material, as seen by the z-scan in confocal microscopy. Moreover, the modification in the water phase, in comparison with organic solvents, was clearly advantageous for preserving the morphology, as observed with SEM. The modification slightly increased the wettability, which might explain the decrease in or undetectable adsorption of adhesive protein shown by QCM-D. Initial cell studies showed that adhesion of human endothelial cells is enhanced when the BC hydrogel is modified with XG-GRGDS. QCM-D studies further revealed that the cell enhancement is due to the presence of the RGD epitope on XG and not to a nonspecific adsorption of fibronectin from cell culture medium. Optimization and proliferation studies of human endothelial cells onto bacterial cellulose modified with XG-GRGDS are currently being carried out at the Vascular Engineering Center, Sahlgrenska University Hospital, Gothenburg.

Mechanical properties of bacterial cellulose and interactions with smooth muscle cells.

Tissue engineered blood vessels (TEBV) represent an attractive approach for overcoming reconstructive problems associated with vascular diseases by providing small calibre vascular grafts. The aim of this study has been to evaluate a novel biomaterial, bacterial cellulose (BC), as a potential scaffold for TEBV. The morphology of the BC pellicle grown in static culture was investigated with SEM. Mechanical properties of BC were measured in Krebs solution and compared with the properties of porcine carotid arteries and ePTFE grafts. Attachment, proliferation and ingrowth of human smooth muscle cells (SMC) on the BC were analysed in vitro. The BC pellicle had an asymmetric structure composed of a fine network of nanofibrils similar to a collagen network. The shape of the stress-strain response of BC is reminiscent of the stress-strain response of the carotid artery, most probably due to the similarity in architecture of the nanofibrill networks. SMC adhered to and proliferated on the BC pellicle; an ingrowth of up to 40 microm was seen after 2 weeks of culture. BC exhibit attractive properties for use in future TEBV.

Production of extracellular matrix components in tissue-engineered blood vessels.

Morphology and compliance of tissue-engineered blood vessels (TEBV) are dependent on the culture period and production of extracellular matrix (ECM) components in order to increase the strength of the developing tissue. The aim of the present study was to evaluate the potential of TEBVs to produce an ECM similar to native arteries and veins. Human smooth muscle cells (SMC) were seeded onto the poly(glycolic acid) (PGA) scaffold and placed in bioreactors filled with DMEM supplemented with growth factors. After 6 weeks, the vessels were harvested from the bioreactors and seeded with human endothelial cells at the lumen for another 3 days. Then, the TEBVs were harvested for RNA and protein isolation for further RT-PCR and Western blot. TEBVs had a similar macroscopic appearance to that of native vessels with no visible evidence of the original PGA. Histological and immunohistochemical analyses indicated the presence of high cell density and development of a highly organized structure of ECM. After 6 weeks of culture, there were significantly lower gene expression of SMC-specific markers, such as alpha-actin, caldesmon, and vimentin, and proteoglycans, such as biglycan, decorin, and versican, and other ECM components, such as collagen I and elastin, in TEBVs, with and without pulsatile conditions, compared to that of native arteries. Gene expression of fibronectin was significantly lower in TEBVs grown during pulsatile conditions compared to that of native arteries. No difference was observed in TEBVs grown during non-pulsatile conditions. The presence of alpha-actin, collagen I, decorin, and fibronectin at protein level was demonstrated in TEBVs with and without pulsatile conditions after 6 weeks and in native veins and arteries as well. How this deviation translates into mechanical properties remains to be explored.

In vivo biocompatibility of bacterial cellulose.

The biocompatibility of a scaffold for tissue engineered constructs is essential for the outcome. Bacterial cellulose (BC) consists of completely pure cellulose nanofibrils synthesized by Acetobacter xylinum. BC has high mechanical strength and can be shaped into three-dimensional structures. Cellulose-based materials induce negligible foreign body and inflammatory responses and are considered as biocompatible. The in vivo biocompatibility of BC has never been evaluated systematically. Thus, in the development of tissue engineered constructs with a BC scaffold, it is necessary to evaluate the in vivo biocompatibility. BC was implanted subcutaneously in rats for 1, 4, and 12 weeks. The implants were evaluated in aspects of chronic inflammation, foreign body responses, cell ingrowth, and angiogenesis, using histology, immunohistochemistry, and electron microscopy. There were no macroscopic signs of inflammation around the implants. There were no microscopic signs of inflammation either (i.e., a high number of small cells around the implants or the blood vessels). No fibrotic capsule or giant cells were present. Fibroblasts infiltrated BC, which was well integrated into the host tissue, and did not elicit any chronic inflammatory reactions. The biocompatibility of BC is good and the material has potential to be used as a scaffold in tissue engineering.

Expression of fibrinolytic and coagulation factors in cocultured human endothelial and smooth muscle cells.

Interactions between endothelial cells and smooth muscle cells are interesting from a tissue-engineering point of view. We have developed a coculture system that allows direct contact between these two cell types. The fibrinolytic factors PAI-1, tPA, and uPA and the coagulation factor TF, were studied at the gene level by RT-PCR and at the protein level by ELISA. Significant changes of all studied factors were seen at the gene level in cocultured endothelial cells. tPA and TF were upregulated 4- and 7-fold, respectively, and PAI-1 and uPA were downregulated 4- and 1.5-fold, respectively, compared with single-cultured controls. In cocultured smooth muscle cells alterations of PAI-1 and TF were significant, with a 1.5-fold upregulation of PAI-1 and a 2.5-fold downregulation of TF. Results at the protein level mirrored the gene expression results. These findings indicate that cocultured endothelial cells are rendered both hypercoagulative and hyperfibrinolytic.

A comparison of the Nottingham Health Profile and Short Form 36 Health Survey in patients with chronic lower limb ischaemia in a longitudinal perspective.

BACKGROUND: Different generic quality of life instruments such as the Nottingham Health Profile (NHP) and the Short Form 36 Health Survey (SF-36) have revealed conflicting results in patients with chronic lower limb ischaemia in psychometric attributes in short-term evaluations. The aim of this study was to compare the NHP and the SF-36 regarding internal consistency reliability, validity, responsiveness and suitability as outcome measures in patients with lower limb ischaemia in a longitudinal perspective. METHODS: 48 patients with intermittent claudication and 42 with critical ischaemia were included. Assessment was made before and one year after revascularization using comparable domains of the NHP and the SF-36 questionnaires. RESULTS: The SF-36 was less skewed and more homogeneous than the NHP. There was an average convergent validity in three of the five comparable domains one year postoperatively. The SF-36 showed a higher internal consistency except for social functioning one-year postoperatively and was more responsive in detecting changes over time in patients with intermittent claudication. The NHP was more sensitive in discriminating among levels of ischaemia regarding pain and more able to detect changes in the critical ischaemia group. CONCLUSION: Both SF-36 and NHP have acceptable degrees of reliability for group-level comparisons, convergent and construct validity one year postoperatively. Nevertheless, the SF-36 has superior psychometric properties and was more suitable in patients with intermittent claudication. The NHP however, discriminated better among severity of ischaemia and was more responsive in patients with critical ischaemia.

[Thoracic and abdominal aorta aneurysms demand an experienced team work]. / Aneurysm i bröst- och bukaorta kräver vältrimmat lagarbete.

Patients with combined aneurysms in the thoracic and abdominal aorta need to be treated at experienced centres. These complicated aneurysms are today treated with various combinations of open and/or endovascular techniques. The complexity of the interventions is associated with high morbidity and mortality. By forming a structured organisation for care of these patients a better outcome can be expected. In this article we present the approach taken in Göteborg to meet these challenges.

An in vitro study of blood compatibility of vascular grafts made of bacterial cellulose in comparison with conventionally-used graft materials.

In this study we analyzed the blood compatibility of bacterial cellulose (BC) as a new biosynthetic material for use as a vascular graft. As reference materials we used expanded polytetrafluoroethylene (ePTFE) and poly(ethylene terephthalate) (PET) vascular grafts. These materials are in clinical use today. Tubes with inner diameters of both 4 (not PET) and 6 mm were tested. Heparin-coated PVC tubes (hepPVC) were used as a negative control. Platelet consumption and thrombin-antithrombin complex (TAT) were used as parameters of coagulation and for complement activation, sC3a and sC5b-9 were used. The investigated parameters were measured after 1-h exposure to freshly drawn human blood supplemented with a low dose of heparin in a Chandler loop system. The results showed that BC exhibits no significant difference in platelet consumption, as compared with PET (6 mm), ePTFE and hepPVC. The PET material consumed more platelets than any of the other materials. The TAT generation for 4 mm tubes was not significantly different between BC and the other materials. For 6 mm tubes, however, differences were observed between hepPVC and PET (p < 0.0001); BC and hepPVC (p = 0.0016); ePTFE and PET (p < 0.0001); BC and ePTFE (p = 0.0029); BC and PET (p = 0.0141). Surprisingly, considering the low platelet consumption, the complement activation parameters (sC3a and sC5b-9) were much higher for BC, as compared with the other materials for both 4 and 6 mm tubes.

Bacterial cellulose modified with xyloglucan bearing the adhesion peptide RGD promotes endothelial cell adhesion and metabolism--a promising modification for vascular grafts.

Today, biomaterials such as polytetrafluorethylene (ePTFE) are used clinically as prosthetic grafts for vascular surgery of large vessels (>5 mm). In small diameter vessels, however, their performance is poor due to early thrombosis. Bacterial-derived cellulose (BC) is a new promising material as a replacement for blood vessels. This material is highly biocompatible in vivo but shows poor cell adhesion. In the native blood vessel, the endothelium creates a smooth non-thrombogenic surface. In order to sustain cell adhesion, BC has to be modified. With a novel xyloglucan (XG) glycoconjugate method, it is possible to introduce the cell adhesion peptide RGD (Arg-Gly-Asp) onto bacterial cellulose. The advantage of the XG-technique is that it is an easy one-step procedure carried out in water and it does not weaken or alter the fiber structure of the hydrogel. In this study, BC was modified with XG and XGRGD to asses primary human vascular endothelial cell adhesion, proliferation, and metabolism as compared with unmodified BC. This XG-RGD-modification significantly increased cell adhesion and the metabolism of seeded primary endothelial cells as compared with unmodified BC whereas the proliferation rate was affected only to some extent. The introduction of an RGD-peptide to the BC surface further resulted in enhanced cell spreading with more pronounced stress fiber formation and mature phenotype. This makes BC together with the XG-method a promising material for synthetic grafts in vascular surgery and cardiovascular research.

Intravital fluorescent microscopic evaluation of bacterial cellulose as scaffold for vascular grafts.

Although commonly used synthetic vascular grafts perform satisfactorily in large caliber blood vessels, they are prone to thrombosis in small diameter vessels. Therefore, small vessels might benefit from tissue engineered vascular grafts. This study evaluated bacterial cellulose (BC) as a potential biomaterial for biosynthetic blood vessels. We implanted the dorsal skinfold chambers in three groups of Syrian golden hamsters with BC (experimental group), polyglycolic acid, or expanded polytetrafluorethylene (control groups). Following implantation, we used intravital fluorescence microscopy, histology, and immunohistochemistry to analyze the biocompatibility, neovascularization, and incorporation of each material over a time period of 2 weeks. Biocompatibility was good in all groups, as indicated by the absence of leukocyte activation upon implantation. All groups displayed angiogenic response in the host tissue, but that response was highest in the polyglycolic acid group. Histology revealed vascularized granulation tissue surrounding all three biomaterials, with many proliferating cells and a lack of apoptotic cell death 2 weeks after implantation. In conclusion, BC offers good biocompatibility and material incorporation compared with commonly used materials in vascular surgery. Thus, BC represents a promising new biomaterial for tissue engineering of vascular grafts.

Real-time measurements of coagulation on bacterial cellulose and conventional vascular graft materials.

The search for a functional, small diameter (<5mm) vascular graft has been ongoing for over 30 years, but yet there is no consistently reliable synthetic graft. The primary mechanisms of graft failure are intimal hyperplasia, poor blood flow and surface thrombogenicity. Bacterial cellulose (BC) became therefore a proposed new biosynthetic vascular graft material. Since conventional methods are not suited for coagulation measurements on BC, we have adapted the automated calibrated thrombin generation method for measurements of biomaterial-induced coagulation of BC as compared with clinically used graft materials i.e., expanded poly(tetrafluoroethylene) (ePTFE) and poly(ethyleneterephtalat) (PET). We have also visualized the coagulation propagation at the material surfaces. Thrombin generation experiments revealed dramatic differences between the materials tested. Both ePTFE and BC were found to generate longer lag times and ttpeak values than PET. Most importantly, BC was found to generate the lowest "peak", indicating a slower coagulation process at the surface. These results are also supported by the measurements of factor XIIa generation and analysis of surface coagulation times, which were detected in the following increasing order (mean + or - SD): PET (27 + or - 8 min)

Engineering microporosity in bacterial cellulose scaffolds.

The scaffold is an essential component in tissue engineering. A novel method to prepare three-dimensional (3D) nanofibril network scaffolds with controlled microporosity has been developed. By placing paraffin wax and starch particles of various sizes in a growing culture of Acetobacter xylinum, bacterial cellulose scaffolds of different morphologies and interconnectivity were prepared. Paraffin particles were incorporated throughout the scaffold, while starch particles were found only in the outermost area of the resulting scaffold. The porogens were successfully removed after culture with bacteria and no residues were detected with electron spectroscopy for chemical analysis (ESCA) or Fourier transform infra-red spectroscopy (FT-IR). Resulting scaffolds were seeded with smooth muscle cells (SMCs) and investigated using histology and organ bath techniques. SMC were selected as the cell type since the main purpose of the resulting scaffolds is for tissue engineered blood vessels. SMCs attached to and proliferated on and partly into the scaffolds.

Influence of cultivation conditions on mechanical and morphological properties of bacterial cellulose tubes.

Bacterial cellulose (BC) was deposited in tubular form by fermenting Acetobacter xylinum on top of silicone tubes as an oxygenated support and by blowing different concentrations of oxygen, that is, 21% (air), 35%, 50%, and 100%. Mechanical properties such as burst pressure and tensile properties were evaluated for all tubes. The burst pressure of the tubes increased with an increase in oxygen ratio and reached a top value of 880 mmHg at 100% oxygen. The Young's modulus was approximately 5 MPa for all tubes, irrespective of the oxygen ratio. The elongation to break decreased from 30% to 10-20% when the oxygen ratio was increased. The morphology of the tubes was characterized by Scanning Electron Microscopy (SEM). All tubes had an even inner side and a more porous outer side. The cross section indicated that the tubes are composed of layers and that the amount of layers and the yield of cellulose increased with an increase in oxygen ratio. We propose that an internal vessel wall with high density is required for the tube to sustain a certain pressure. An increase in wall thickness by an increase in oxygen ratio might explain the increasing burst pressure with increasing oxygen ratio. The fermentation method used renders it possible to produce branched tubes, tubes with unlimited length and inner diameters. Endothelial cells (ECs) were grown onto the lumen of the tubes. The cells formed a confluent layer after 7 days. The tubes potential as a vascular graft is currently under investigation in a large animal model at the Centre of Vascular Engineering, Sahlgrenska University