Expert Review of Medical Devices

ISSN: 1743-4440 (Print) 1745-2422 (Online) Journal homepage: http://www.tandfonline.com/loi/ierd20

Tissue Engineered Vascular Grafts: Current State

of the Field

Chin Siang Ong, Xun Zhou, Chen Yu Huang, Takuma Fukunishi, Huaitao
Zhang & Narutoshi Hibino

To cite this article: Chin Siang Ong, Xun Zhou, Chen Yu Huang, Takuma Fukunishi, Huaitao
Zhang & Narutoshi Hibino (2017): Tissue Engineered Vascular Grafts: Current State of the Field,
Expert Review of Medical Devices, DOI: 10.1080/17434440.2017.1324293

To link to this article: http://dx.doi.org/10.1080/17434440.2017.1324293

Accepted author version posted online: 27

Apr 2017.

Submit your article to this journal

Article views: 3

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ierd20

Download by: [The UC San Diego Library] Date: 02 May 2017, At: 03:14
Publisher: Taylor & Francis

Journal: Expert Review of Medical Devices

DOI: 10.1080/17434440.2017.1324293
REVIEW

Tissue Engineered Vascular Grafts: Current State of the Field

Chin Siang Ong, MBBS1#, Xun Zhou, MD1#, Chen Yu Huang, PhD2, Takuma Fukunishi,
MD1, Huaitao Zhang, BS1, Narutoshi Hibino, MD PhD1*
1
Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
2
Department of Physics & Astronomy, Johns Hopkins University, Baltimore, Maryland,
USA
#
These authors contributed equally to this work.

*Corresponding Author:
Narutoshi Hibino, MD
Division of Cardiac Surgery
The Johns Hopkins Hospital
Zayed 7107, 1800 Orleans St, Baltimore, MD 21287, USA
Email: nhibino1@jhmi.edu

Key Words: Tissue Engineered Vascular Grafts, Vascular Surgery, Vascular Grafts, Cell
seeding, Biomaterial
Abstract

Introduction:
Conventional synthetic vascular grafts are limited by the inability to remodel, as well as
issues of patency at smaller diameters. Tissue-engineered vascular grafts (TEVGs),
constructed from biologically active cells and biodegradable scaffolds have the potential
to overcome these limitations, and provide growth capacity and self-repair.

Areas covered:
This article outlines the TEVG design, biodegradable scaffolds, TEVG fabrication
methods, cell seeding, drug delivery, strategies to reduce wait times, clinical trials, as
well as a 5-year view with expert commentary.

Expert Commentary:
TEVG technology has progressed significantly with advances in scaffold material and
design, graft design, cell seeding and drug delivery. Strategies have been put in place
to reduce wait times and improve “off-the-shelf” capability of TEVGs. More recently,
clinical trials have been conducted to investigate the clinical applications of TEVGs.
 1. Introduction

Vascular grafts fulfill an important role in the contemporary management of a wide

range of clinical conditions. In addition to atherosclerotic disease, many vascular
pathologies, including aneurysmal degeneration, congenital malformations, vasculitis,
and traumatic injury necessitate arterial bypass. In most cases, autologous tissue, such
as internal thoracic artery or saphenous vein, is the first choice for small diameter
arterial grafts. However, prior surgeries and comorbid medical conditions may limit the
availability of a patient’s own vessels, and their harvest can be associated with
significant morbidity. While synthetic grafts demonstrate good patency and long term
outcomes for management of the aorta and other large arteries, their use for bypass of
small diameter vessels has been associated with less than satisfying results1. Long
term outcomes are negatively impacted by high rates of thrombus formation and intimal
hyperplasia. Therefore, there remains a substantial unfulfilled need for readily available
small-caliber vascular grafts with good long-term patency2. For pediatric patients,
homografts and synthetic grafts are a source of morbidity, due to the lack of growth
potential and inflammatory reactions associated with these grafts. There is an unmet
clinical need for new vascular grafts that have growth potential.

Robert Langer and Joseph Vacanti defined the concept of tissue engineering in 1993 in
their seminal Science paper “Tissue Engineering” where they defined the term as "an
interdisciplinary field that applies the principles of engineering and life sciences toward
the development of biological substitutes that restore, maintain, or improve tissue
function"3.

The principle of “tissue engineering” has been applied to create tissue engineered
vascular grafts (TEVGs) using a patient’s autologous cells or a patient’s stem cell-
derived cells, in combination with a scaffold4-6. Early pioneering work in this field was
performed in the 1980s when Greisler implanted woven absorbable polyglycolic acid
(PGA) grafts into rabbit aortas and demonstrated replacement of the prosthesis with
endothelialized vessels at 7 months. While nearly a quarter of the specimens
demonstrated either dilation or intimal hyperplasia, all were able to withstand arterial
perfusion pressure7. The strengths and weaknesses of Greisler’s experiment
highlighted the properties that a TEVG should exhibit. At the most basic level, a graft
must be biocompatible and not exhibit toxicity or excessive immunogenicity. An ideal
TEVG5 should have the mechanical properties to maintain a balance between
degradation and neotissue formation. From a functional standpoint, TEVGs should be
biomimetic and resist long-term complications, such as infection, intimal hyperplasia,
stenosis, calcification, and aneurysmal dilatation. Logistically, it is also important that
the manufacturing process for a TEVG be resilient, minimize production time, and in the
case of unseeded TEVGs, allow for storability in order to optimize “off-the-shelf”
capabilities8.

2. TEVG design
Most TEVGs seek to replicate the biological and mechanical properties of native blood
vessels, if not the protein, materials and cells themselves present in native vascular
architecture. At a histological level, mammalian arteries consist of three layers – intima,
media, and adventitia.

The innermost intimal layer consists of endothelial cells (ECs), which provide a tight
luminal barrier while also providing cellular signaling that prevents thrombosis, infection,
and inflammation. These cells are adhered to a basement membrane comprised of
collagen and laminin. The media is comprised of smooth muscle cells (SMCs)
imbedded in a layer of type I and III collagen. In response to the appropriate signals,
these SMCs will contract or relax, resulting in vasoconstriction or vasodilation. The
media is sandwiched between the internal and external elastic lamina, fenestrated
layers of elastin which interface with the intima and the adventitia, the outermost layer of
the arterial wall. The adventitia consists of fibroblasts in a loose extracellular matrix
comprised mostly of collagen. The extracellular matrix of native vessels consists of a
network of multiple proteins in media and adventitia, which serve distinct mechanical
and biochemical purposes.

Collagen is the primary component of extracellular matrix, providing tensile strength.

Thus, it plays an important role in the design of TEVGs. As it is easily isolated and
synthesized, it has been utilized as a substrate for engineered protein matrices. Elastin
is another major component of extracellular matrix, providing elastic recoil to the arterial
wall. Its paracrine functions include modulating the proliferation of endothelial and
smooth muscle cells. Elastin has been used as a coating for synthetic vascular grafts,
such as PTFE, and has been shown to decrease platelet activation, aggregation, and
thrombus formation. Like collagen, elastin has been shown to be synthesized in
biologically significant quantities by TEVGs9. Finally, fibrin is a component of blood
vessels, that is formed when fibronogen is rapidly polymerized by action of thrombin. It
recruits cells, and is broken down by fibrinolysis. The presence of native proteins in
TEVGs allow for relevant cellular signaling that promotes a more native-like immediate
microenvironment, and better biomimicry. TEVGs attempt to recapitulate the functions
of each component in the vessel by promoting cellular infiltration and proliferation to
facilitate the synthesis of these proteins.

3. Scaffolds

The essential concept driving the field of TEVGs is biomimicry5. The scaffold for TEVGs
offers the ability of neotissue formation. The TEVG undergoes remodeling through the
body’s innate response to foreign material and the scaffold is eventually replaced by
autogenous tissue. There are different types of scaffolds that can be used for TEVG.
Each scaffold has advantages and disadvantages. Further research is required to
improve the material of the scaffolds.

3-1: Synthetic Scaffolds

Most scaffolds employed in TEVGs are constructed from biodegradable polymers
(Table 1). These polymers are degraded by hydrolytic cleavage of ester linkages. The
rate of degradation can be modulated by multiple factors, including molecular weight,
surface-area-to-volume ratio, and crystallinity. When compared to methods that utilize
biological proteins such as collagen, synthetic polymers facilitate less cellular
recruitment, but they allow for improved mechanical properties that make them more
feasible for grafts subject to arterial pressure.

One of the most commonly and widely studied polymers is PGA, the material utilized by
Greisler in his early studies in the 1980s. PGA exhibits rapid degradation within 1
month10. PGA mesh has been employed in other experimental and clinical applications
with FDA approval, including scaffolds for nerve regeneration, repair of dural tears, and
in the tissue engineering of liver, bone, cartilage, and intestine. Therefore, its
mechanical properties are well-documented and understood. Mauri and colleagues
demonstrated that a PGA TEVG with human ECs should be able to withstand
mechanical stress equivalent to aortic pressure by comparing to aortic tissue11.

Polylactic acid (PLA) is similar in structure to PGA, with the addition of a single methyl
group, causing it to be more hydrophilic. Therefore, it degrades more slowly than PGA,
taking months to years. PLA is available as either a racemic mixture or a pure
enantiomer (poly-L-lactic acid, PLLA), which takes longer to degrade. Like PGA, PLA
has also been employed in many clinical applications including tissue engineering.12
PLA has 3 isomeric forms, of which poly-l-lactic acid (PLLA) is the most studied for
cardiovascular tissue engineering applications13.

Poly-ε-caprolactone (PCL)14-16 is one of the most hydrophilic and degradation-resistant

biodegradable polymers commonly used, taking more than 1 year to be broken down.
When compared to PGA and PLA, PCL is also notable for having a lower glass-
transition temperature of -60⁰C, meaning that it will be remain stable as a polymer at
room temperature and during refrigeration.

Scaffolds can also be constructed from copolymers17 of two or more components, such
as copolymer of ε-caprolactone and lactic acid (PCLA) and of copolymer of glycolic acid
and lactic acid (PLGA), resulting in intermediate properties and degradation times. By
varying the ratio of the component monomers, these properties can be finely adjusted.
However, immiscibility, reduced polymerization and crystallinity can cause more rapid
degradation times.

Groups have also experimented with using fast-degrading scaffolds. Wu and colleagues
created electrospun PGS/PCL grafts that were used in a rat aorta model. No cells were
seeded, but 3 months after interposition grafting in rat abdominal aorta, the grafts
rapidly degraded, forming neoarteries with synchronous pulsation, confluent endothelial
and smooth muscle layers, expressing elastin, collagen and glycosaminoglycan, with
native-like mechanical properties15.
Other synthetic polymers used are poly-ethylene-glycol (PEG)13, poly-urethane
(PU)13,18, poly-hydroxy-alkanoate (PHA)19, poly-hydroxy-octanoate (PHO)20, poly-
diaxanone (PDS)21, poly-glycerol-sebacate (PGS)22, poly-ester-urethane-urea
(PEUU)23,24, poly-4-hydroxy-butyrate (P4HB)25,26, amongst others.

3-2: Biological scaffolds

There are also a number of strategies for creation of biological TEVGs, such as self-
assembly, hydrogels, and decellularized biological matrices. Biological material, such as
collagen27, fibrin28-30, are also frequently used in these constructs.

Hydrogels31 attempt to directly recapitulate the structure of native vessels by embedding

cells within a solubilized protein matrix, generally consisting of collagen and/or
additional proteins. The solution can then be molded into a desired shape, such as a
tubular structure for vascular grafts, and then solidified. Stem cells or other progenitor
cells are commonly used in hydrogels, with the goal of encouraging cellular signaling,
proliferation, and recruitment to promote remodeling into vascular tissue. However,
while hydrogels have been employed broadly in tissue-engineering applications, they
often lack the mechanical properties needed for functional vascular grafts. Many
strategies have been proposed to overcome this limitation, such as supplementation
with growth factors, such as vascular endothelial growth factor32,33, constructing
multilayer grafts34,35, and chemical/enzymatic cross-linking of the protein matrix36,37.

Intact extracellular matrices can be also be obtained by decellularizing native vascular

tissue, with the goal of removing all immunogenic components while preserving
biological and mechanical properties. For example, Syedain and colleagues38 also
implanted an decellularized engineered tissue tubes in lambs and evaluated them to
adulthood. The lambs increased in weight by 366%, and the graft diameter and volume
increased by 56% and 216% respectively. Mechanical, chemical, and enzymatic
processes can be employed for the decellularization process, and, theoretically, both
homografts and xenografts from other species can be utilized. The advantages of this
approach include a more natural structure, containing functional proteins to promote
cellular recruitment. One disadvantage of this approach is the possibility of
immunogenicity from antigens of retained cellular remnants, which remains to be
determined39, although the decellularization process seeks to minimize this risk.

Another novel approach towards developing an extracellular matrix is through cell sheet
self-assembly31,40. When cultured in a medium enriched with ascorbic acid, the
substrate for collagen synthesis, smooth muscle cells and fibroblasts can directed to
synthesize their own extracellular matrix. In vitro, this can be performed a cylindrical
mandrel to generate a tubular structure. Other groups have also demonstrated that this
process can also be performed in vivo, by implanting synthetic tubing into the peritoneal
cavity and relying on the body’s inflammatory response to form a layer of granulation
tissue around the structure. Once explanted, this granulation tissue can be harvested
and everted to obtain a mesothelialized sleeve of collagen extracellular matrix and
fibroblasts41.
3-3: Hybrid scaffolds

Building scaffolds that combine degradable synthetic and natural polymers may provide
good mechanical properties while also enhancing biocompatibility and cellular
recruitment. Hajiali and colleagues created electrospun PGA scaffolds blended with
different concentrations of gelatin, and found that increased gelatin consult improved
biological and mechanical properties42. Similarly, Xie and colleagues created PLA/PLCL
grafts impregnated with collagen/elastin43. Gong and colleagues electrospun a
biodegradable polymer around decellularized rat aortas to create a hybrid scaffold
TEVG44.

TEVGs can also be combined with stents to create hybrid stent-grafts. Takeuchi and
colleagues created a stent-graft with double-layered polyethylene terephthalate
(PET)/PGA that was used in a dog aorta model of endovascular aneurysm repair
(EVAR). It demonstrated similar tensile strength and flexibility as a traditional polyester
graft, with PGA degradation and replacement by host tissue in vivo 2 months post-
implantation45.

4. TEVG Fabrication Methods

One of the most popular techniques for creating a degradable polymer scaffold is
electrospinning. The process uses an electric field to direct a jet of polymer solution
from a capillary tip towards a target for deposition. In order to create a tubular structure
such as an arterial scaffold, a rapidly rotating mandrel is used as a target46. By varying
parameters such as the, flow rate, voltage, polymer concentration, distance, surface
speed, and solvent, the thickness, density, and physical properties of the resulting
scaffold can be altered. Studies have demonstrated that high burst pressures and
tensile strength akin to physiological parameters can be obtained by simply varying
deposition time47.

Another common method is particulate or porogen leaching48, where particulates or

porogens (salt, sugar, wax) serve as placeholders for pore formation in the actual
scaffold, before being leached by evaporation, cross linking or by another chemical
reaction.

Freeze-drying (lyophilization)15,49,50 is based on the principle of sublimation, where a

polymer is first dissolved in a solvent. This solution is frozen and the solvent is allowed
to sublime during the drying process. Pore size51 can be controlled by changing
conditions, such as freezeing rate and solute concentration.

Other techniques to fabricate scaffolds52 include solvent casting, foaming, phase

separation, fiber mesh, fiber bonding, self assembly, rapid prototyping, melt molding,
and membrane lamination. Bioreactors may also be used, for example, Gui and
colleagues used a pulsatile bioreactor to culture SMCs on PGA scaffolds on silicone
backbones53, and Syedain and colleagues used custom pulsed-flow-stretch bioreactors
to engineer tissue tubes prior to decellularization38.

Im and colleagues demonstrated a novel technique of solid-state drawing to produce a

TEVG with good mechanical properties without the need for solvents or additional
treatments. Their methodology consisted of dual rotary motors on either side of a
heating oven to mechanical stretch a biodegradable polymer. Functional studies
demonstrated that their resulting product exhibited improved tensile strength and
hydrophobicity. Additionally, spectroscopy demonstrated increased molecular
orientation, which translates into a smoother surface that is less likely to cause platelet
aggregation54.

Scaffolds can also be made of customized graft material and graft designs. Sugiura and
colleagues developed two versions of bilayer copolymeric grafts, one fast-degrading
(FD) and the other slow-degrading (SD). The SD grafts consisted of a double-layer of
PLA/PLCL. The outer layer of the FD grafts consisted of a blend of PLA-PGA. In a
mouse aorta model, the FD grafts had better cellular infiltration, and less calcification55.
Other attempts at multilayer grafts include adding a thick porous hydrogel sleeve to a
dense nanofibrous core (PCL)35 and adding hydrogel solutions between a mandrel and
a hydrated PU mesh34. In an attempt to emulate the J-shaped mechanical behavior of a
two-component elastin/collagen system, Rapoport and colleagues electrospun PU with
PGA to form a corrugated graft56.

5. Cell seeding for TEVG

5-1: Cell Seeding Techniques

There are numerous techniques57 to perform cell seeding. Passive seeding (static
seeding and gravitational seeding)58 is the most common approach but also the least
efficient approach and involves direct application of the cell suspension into the scaffold,
either luminally or from the outside. Fibronectin or other adhesive biological glues may
also be used as well59.

Dynamic seeding uses various systems to increase seeding efficiency, uniformity and
penetration of the scaffold. Generally, the two main types are rotational seeding60 that
induces hydrostatic forces, or vacuum seeding61 that creates pressure gradients to draw
cells in through the micropores of the TEVG.

Electrostatic cell seeding and magnetic cell seeding aim to increase seeding efficiency
through the use of a temporary positive charge on the typically negatively charged
TEVG luminal surface for the former62, and the use of magnets and
magnetite nanoparticles for the latter63. Other techniques57 include photopolymerized
hydrogels64 for cell seeding, sheet-based cell seeding65 and hybrid systems66.

Assessment of cell seeding can be performed by cell counting, quantitative histology, scanning
electron microscopy and picogreen (DNA) detection assay, followed by assessment of viability
by MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrasodium bromide) assay and live-dead
assays.

5-2: Cell Types Used in Seeding

There have been a number of different cell types used in cell seeding67, such as adult
blood vessel cell types, endothelial progenitor cells (EPCs), stem cells, and stem cell
derived vascular cells68.

Adult blood vessel cell types include endothelial cells, smooth muscle cells and
fibroblasts but these cell types involve a blood vessel biopsy which may result in
morbidity during harvesting at the donor sites69 and have limited replicative ability due to
patient’s age70. This cell source is usually autologous, though nonautologous sources
utilizing allogeneic cells have been described71.

EPCs may also be used for cell seeding, and can be obtained using far less invasive
methods than adult blood vessel cell types, by extraction from peripheral blood.
Asahara and colleagues isolated endothelial progenitor cells (EPCs) from human
peripheral blood using cell surface antigen expression and magnetic bead selection72.
Shirota and colleagues collected human peripheral blood samples, excluded monocytes
and macrophages and expanded EPCs in vitro. They then seeded these cells into a
small diameter vascular grafts and demonstrated elongation and alignment of EPCs
along the direction of blood flow73. However, it is important to note that EPCs represent
a relatively heterogeneous cell population74.

Mesenchymal stem cells (MSCs) are adult stem cells that have the capability to form a
variety of connective tissue phenotypes, including blood vessels. They are readily
isolatable from bone marrow, peripheral blood, skeletal muscle, and adipose tissue.75
While bone marrow aspiration has historically been the preferred method for obtaining
MSCs from bone marrow mononuclear cells76-78 (BM-MNCs), liposuction79 or skeletal
muscle biopsy23 are also adequate, even from the hair follicle in the skin dermis80.
MSCs obtained through each of these techniques have been successfully utilized in
TEVGs, although there is evidence that the source of MSCs may affect the
biomechanical properties of the resulting grafts. Potentially, MSCs could be harvested
from a patient, expanded in vitro, and used for a personalized TEVG without the need
for additional cell culture81.

Embryonic stem cells (ESCs) have the potential to differentiate into any adult cell type.
For the purposes of TEVG, they are appealing because of their proliferative capability
and versatility, but also pose numerous concerns. In addition to ethical considerations,
there are substantial biological concerns regarding potential tumorigenicity and stability
in terms of lineage commitment during differentiation. One study of vascular grafts
constructed with human ESCs, found evidence of bone and cartilage markers,
suggesting that some of the cells in the mature graft have differentiated into to
osteoblasts and chondrocytes and that stringency in analyzing differentiating cell
population is warranted82.
As an alternative to ESCs, groups have investigated the use of induced pluripotent stem
cells (iPSCs)83. These cells are generated by de-differentiating mature adult cells, often
from skin or blood. iPSCs were then differentiated into vascular smooth muscle cells via
an embryoid body approach53,84 or in a defined medium in the presence of Wnt3a for 10
to 12 days for neural crest induction, before further induction into a mesenchymal
lineage and confirmation of MSC phenotype85.

Hibino and colleagues demonstrated that mouse iPSCs could be seeded on PLGA and
PCLA scaffolds in a mouse inferior vena cava model with good endothelialization86. Gui,
Sundaram and colleagues used human iPSCs in an aortic interposition model in nude
mice with good outcomes (no ruptures, stenosis, or teratomas at 2 weeks)53,85.
However, the number of seeded differentiated iPSCs decreased over time (42% at 1
week, 10% at 4 weeks and 10 weeks)86.

5-3: Effect of Cell Seeding

The use of cell seeding remains controversial57, with unanswered questions regarding
the necessity and clinical relevance of high efficiency cell seeding, quantification
method of cell seeding, optimal cell type for seeding and the fate and function of seeded
cells. The fate of the seeded cells remain uncertain, with Cho and colleagues showing
decreasing cell density by fluorescence intensity over 8 weeks69. It has been proposed
that seeded cells are lost due to cell death or lack of cellular attachment with resultant
embolization to the distal end-organs57. Studies performed by Lee and colleagues, to
investigate the duration of incubation and cell dose, on seeding efficiency and cellular
attachment, showed that incubation time does not affect TEVG patency, cell attachment
and seeding efficiency and that macrophage infiltration and inhibition of critical stenosis
occurs in a cell dose-dependent manner87.

6. Drug delivery

Various groups have investigated strategies for delivering or embedding

pharmacological agents within the graft to enhance their biocompatibility and functional
properties. There are generally two approaches, direct addition of drug into the material
used for vascular graft creation and drug loading into the vessels or grafts.

Examples of drug addition into the material for graft creation include Lee and
colleagues, who applied a polymeric local drug delivery technique by electrospinning
PLGA with epigallocatechin-3-O-gallate (EGCG), a green tea polyphenol, to prevent
intimal hyperplasia in a rabbit aorta model88. Centola, Spadaccio and colleagues
developed a heparin-releasing poly-L-lactide (PLLA) scaffold using electrospinning.
Heparin in the graft helps to guide MSC differentiation towards the endothelial cell type
(determined by CD31 positivity and morphology) and also as a postoperative drug89,90.

In terms of drug loading into the vessel or grafts, Zou and colleagues created treated rat
internal jugular veins with rapamycin-containing PLGA nanoparticles and used them for
carotid interposition grafts, finding they inhibited neointimal hyperplasia91. Similarly,
Duncan and colleagues used PLGA nanoparticles to deliver a TGF-β inhibitor to prevent
TEVG stenosis in their mouse model92. Dimitrievska and colleagues used a novel
method of “click chemistry” to conjugate oriented heparin moieties onto decellularized
aortas in order to improve blood compatibility93.

7. Strategies to reduce wait times

One major impediment to the clinical implementation of TEVGs is the waiting time for
graft creation. The use of autologous cells requires longest wait times, up to months94.
In low pressure systems, Hibino and colleagues demonstrate a technique for harvesting
bone marrow, isolating cells, seeding them, and implanting them on the same day95.
Dahl, Quint and colleagues cultured human/dog SMCs on a PGA scaffold that was
subsequently decellularized, and tested them in models of coronary bypass and AV
grafts which demonstrated good functional outcomes and showed progress towards
“off-the-shelf”96,97. Krawiec and colleagues developed a culture-free method of
differentiating MSCs obtained from liposuction into SMCs that were used in TEVGs75.
Acellular grafts8, such as the Humacyte Acellular Vessel (HAV)96, are also helpful in
decreasing waiting times.Clinical Trials

There are several reports of clinical trials for TEVGs. Shinoka, Hibino and colleagues
reported a clinical trial of PGA/PCL or PLA grafts used for extracardiac cavopulmonary
shunts in children. At a mean follow-up interval of 5 years, there is no evidence of
aneurysm, rupture, or calcification, although graft stenosis is the primary mode of graft
failure98-100. Lawson and colleagues performed two phase 2 studies of their
decellularized PGA scaffold TEVG (seeded with SMCs from donors) as upper limb
arteriovenous grafts in 60 renal patients requiring hemodialysis and demonstrated
safety (1 infection in 82 patient-years of follow up) and efficacy (patency)101. Bockeria
and colleagues also performed a clinical trial of vascular grafts (PCL with 2-ureido-
4[1H]-pyrimidinone (UPy) motif) as extracardiac cavopulmonary conduits in 5 pediatric
patients undergoing Fontan surgery.102 At 1 year, there were no device related adverse
events and the implanted grafts demonstrated stable conduit diameters, lengths, wall
thicknesses and blood flow patterns. McAllister and colleagues have also conducted a
multi-center cohort study of the effectiveness of hemodialysis access for renal patients
using TEVGs, and found that their primary patency rate approaches established quality
objectives for arteriovenous (AV) fistulas103. More recently, the group followed up with a
study using TEVGs built from allogeneic fibroblasts implanted as brachial-axillary AV
shunts for 3 patients requiring hemodialysis access71. Various biodegradable scaffolds
are currently undergoing clinical evaluation for the treatment of coronary artery
disease104.

8. Expert commentary

The short supply of autologous grafts and the limitations of synthetic grafts, especially
for small-diameter arterial applications, will ensure the continued need for TEVGs.
As discussed in this review, TEVG technology has improved markedly, with advances
made in scaffold material (synthetic, biological, hybrid), TEVG design and TEVG
fabrication methods. In addition, many different types of cells have been seeded into
TEVGs, using a variety of seeding techniques. Drug delivery in the TEVGs has also
been attempted, either as a component of the material used to create the TEVGs, or
drug loading after TEVG creation. To decrease wait time and improve the “off-the-shelf”
capability of TEVGs, the use of same-day harvesting, seeding and implantation, and
use of decellularized or acellular TEVGs show promise. Finally, clinical trials
investigating TEVGs have been successfully conducted.

However, it is still challenging to develop ideal materials for TEVGs. Firstly, stenosis
caused by excessive inflammatory reaction to graft materials is the primary mode of
graft failure and needs to be addressed. In particular, the development of small
diameter grafts is still challenging, due to graft stenosis.

Some mechanisms have been proposed for immune response to materials, such as
pathways involving inflammation105, the innate immune system106 and upregulation of
TEVG matrix metalloproteinase activity26. In addition, it has been demonstrated that
endothelial cells and smooth muscle cells migrated from adjacent tissue play an
important role in preventing graft stenosis107. Secondly, proper extracellular matrix
(ECM) formation is key for balanced neotissue formation. Successful formation of ECM
requires the degradation and remodeling of graft materials by infiltrating host cells.
Rapid degradation of grafts does not allow sufficient time for the deposition of adequate
ECM, resulting in aneurysm formation or graft rupture. While slow degradation materials
can provide mechanical support and prevent rupture of the grafts, they also prevent
ECM formation and cause long lasting foreign body material reaction, which promotes
calcification within the grafts. Thus, there is a need to discover and develop grafts, that
are optimized for degradation kinetics and ECM deposition. More basic science
research into TEVGs can aid in improving the understanding of the process of TEVG
remodeling, leading to development of better and more optimized TEVGs.

In terms of clinical trials, the regulatory hurdle remains high and there is a need for new
materials to demonstrate proven biocompatibility with human tissues before approval is
granted. This process frequently takes a very long time. It is also difficult to accurately
predict TEVG degradation and inflammatory response in humans, based on data from
preclinical animal studies. Despite these, clinical trials must continue, so the ultimate
aim of conducting TEVG research for the advancement in human healthcare and the
medical sciences, may be fulfilled. TEVG research has clinical implications that can be
applied broadly in the fields of vascular surgery and heart surgery, and can be applied
to patients of all age groups, from pediatric patients undergoing congenital heart surgery,
to elderly patients with end stage renal disease requiring vascular access for
hemodialysis.
9. Five-Year View

TEVG technology will improve, with the use of innovative techniques to overcome
limitations, advances in nanotechnology108, electrospinning109 and refinement in
decellularization techniques108. Materials and biomaterials will improve, with
investigators seeking “ideal” TEVGs that will be increasingly “off-the-shelf”, more cost
effective, with better biocompatibility, in terms of long term patency and neotissue
formation110,111. In addition, these TEVGs will have improved mechanical strength and
better ability to withstand arterial pressures14,109, better cellular infiltration by controlling
pore size and optimizing speed of scaffold degradation110.

In addition, TEVGs will be more patient-specific. This will likely be due to the increasing
use of stem cells and stem cell-derived vascular cells68, and supporting cells such as
pericytes112, thus promoting patient-specific vascular regeneration, as well as the use of
3D bioprinting and 3D printing technologies111,113 and innovative new systems to allow
for ease and safety of cell seeding without specialized equipment110.

Finally, the clinical use of TEVGs will increase. There are a number of preclinical large
animal studies and some clinical trials98-101, and it is likely that there will be more studies
in large animal models to assess clinical applicability110, leading to more widespread
clinical use5.

10. Conclusions

TEVGs have significant benefits over conventional grafts by allowing for growth, tissue
remodeling and self-repair. TEVGs show great promise in all fields of vascular surgery,
but especially so in pediatric cardiac surgery, where patients have to undergo repeated
surgeries as their circulation systems outgrow implanted conventional grafts of fixed
diameters102. In TEVG creation, there are many different cell types that can be used,
including regenerative stem cells, and many different scaffolds with synthetic, biological
and hybrid scaffolds. Drugs can be delivered by impregnating TEVG material such as
nanofibers or loading post TEVG creation. The major limitations at the moment include
limited experience with arterial grafts and clinical trials. The search for the ideal TEVG
continues.

Key issues

• TEVGs offer significant benefits by allowing for growth, tissue remodeling, and
self-repair, compared to conventional vascular grafts.
• TEVGs have shown promise in all fields of vascular surgery, especially in
pediatric surgery.
• There are many different types of scaffolds that can be used to create TEVGs,
i.e. synthetic, biological, or hybrid scaffolds.
• TEVGs can be seeded with many different cell types, ranging from mature
somatic cells, stem cells, to stem cell-derived cells.
• Drug delivery can be done, by impregnating TEVG material before TEVG
creation or drug loading after TEVG creation.
• While some clinical trials have been conducted, TEVGs have not been widely
used clinically.
• There is limited use of TEVGs clinically due to the time consuming process of
TEVG fabrication, costs, as well as limitations with respect to cell sources and
graft materials.
• The search for the ideal TEVG remains.
Funding

This paper was not funded.

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization
or entity with a financial interest in or financial conflict with the subject matter or
materials discussed in the manuscript. This includes employment, consultancies,
honoraria, stock ownership or options, expert testimony, grants or patents received or
pending, or royalties.

Figure Legend

Figure 1: TEVGs: Fabrication Methods (Left Top), Scaffolds (Top Right), Cell Types
(Left Bottom), Clinical Application (Bottom Right)
 Table 1

Scaffold material
Poly-glycolic acid (PGA) 10,11
Poly-lactic acid (PLA) 12,13
Poly-ε-caprolactone (PCL)14-16
Poly-ethylene-glycol (PEG)13
Poly-urethane (PU)13,18
Poly-hydroxy-alkanoate (PHA)19
Poly-hydroxy-octanoate (PHO)20
Poly-diaxanone (PDS)21
Poly-glycerol-sebacate (PGS)22
Poly-ester-urethane-urea (PEUU)23,24
Poly-4-hydroxy-butyrate (P4HB) 25,26
Co-polymers17

Examples of scaffold materials used in TEVG fabrication.

References

Papers of special note have been annotated as:

* Of interest
** Of considerable interest

1. Esquivel CO, Blaisdell FW. Why small caliber vascular grafts fail: a review of
clinical and experimental experience and the significance of the interaction of
blood at the interface. The Journal of surgical research. 1986;41(1):1-15.
2. Greenwald SE, Berry CL. Improving vascular grafts: the importance of
mechanical and haemodynamic properties. The Journal of pathology.
2000;190(3):292-299.
3. Langer R, Vacanti JP. Tissue engineering. Science (New York, N.Y.).
1993;260(5110):920-926. ** This is a seminal paper defining the concept of
tissue engineering.
4. L'Heureux N, Dusserre N, Marini A, Garrido S, de la Fuente L, McAllister T.
Technology Insight: the evolution of tissue-engineered vascular grafts - from
research to clinical practice. Nat Clin Pract Cardiovasc Med. 2007;4(7):389-395.
5. Benrashid E, McCoy CC, Youngwirth LM, et al. Tissue engineered vascular
grafts: Origins, development, and current strategies for clinical application.
Methods (San Diego, Calif.). 2016;99:13-19.
6. Langer R, Vacanti J. Advances in Tissue Engineering. Journal of pediatric
surgery. 2016;51(1):8-12.
7. Greisler HP. Arterial regeneration over absorbable prostheses. Arch Surg.
1982;117:1425-1431.
8. Manson RJ, Unger JM, Ali A, Gage SM, Lawson JH. Tissue-engineered vascular
grafts: autologous off-the-shelf vascular access? Seminars in nephrology.
2012;32(6):582-591.
9. Lee K-W, Stolz DB, Wang Y. Substantial expression of mature elastin in arterial
constructs. Proceedings of the National Academy of Sciences of the United
States of America. 2011;108:2705-2710.
10. Mooney DJ, Mazzoni CL, Breuer C, et al. Stabilized polyglycolic acid fibre-based
tubes for tissue engineering. The Biomaterials: Silver Jubilee Compendium.
2006;17:129-138.
11. Mauri A, Zeisberger SM, Hoerstrup SP, Mazza E. Analysis of the uniaxial and
multiaxial mechanical response of a tissue-engineered vascular graft. Tissue
engineering. Part A. 2013;19:583-592.
12. Kurobe H, Maxfield MW, Tara S, et al. Development of small diameter nanofiber
tissue engineered arterial grafts. PLoS ONE. 2015;10.
13. Liu X, Wang S. Tissue Engineering, Cardiovascular: Biodegradable Polymers. In:
Mishra M, ed. Encyclopedia of Biomedical Polymers and Polymeric Biomaterials.
1st ed: Taylor & Francis; 2015:7957-7971.
14. Fukunishi T, Best CA, Sugiura T, et al. Tissue-Engineered Small Diameter
Arterial Vascular Grafts from Cell-Free Nanofiber PCL/Chitosan Scaffolds in a
Sheep Model. PLOS ONE. 2016;11:e0158555.
15. Wu W, Allen RA, Wang Y. Fast-degrading elastomer enables rapid remodeling of
a cell-free synthetic graft into a neoartery. Nature Medicine. 2012;18:1148-1153.
16. Iwasaki K, Kojima K, Kodama S, et al. Bioengineered three-layered robust and
elastic artery using hemodynamically-equivalent pulsatile bioreactor. Circulation.
2008;118(14 Suppl):S52-57.
17. Matsumura G, Isayama N, Matsuda S, et al. Long-term results of cell-free
biodegradable scaffolds for in situ tissue engineering of pulmonary artery in a
canine model. Biomaterials. 2013;34(27):6422-6428.
18. Sharifpoor S, Simmons CA, Labow RS, Paul Santerre J. Functional
characterization of human coronary artery smooth muscle cells under cyclic
mechanical strain in a degradable polyurethane scaffold. Biomaterials.
2011;32(21):4816-4829.
19. Shum-Tim D, Stock U, Hrkach J, et al. Tissue engineering of autologous aorta
using a new biodegradable polymer. Ann Thorac Surg. 1999;68(6):2298-2304;
discussion 2305.
20. Marois Y, Zhang Z, Vert M, Beaulieu L, Lenz RW, Guidoin R. In vivo
biocompatibility and degradation studies of polyhydroxyoctanoate in the rat: a
new sealant for the polyester arterial prosthesis. Tissue engineering.
1999;5(4):369-386.
21. Sell SA, McClure MJ, Barnes CP, et al. Electrospun polydioxanone-elastin
blends: potential for bioresorbable vascular grafts. Biomedical materials (Bristol,
England). 2006;1(2):72-80.
22. Lee KW, Johnson NR, Gao J, Wang Y. Human progenitor cell recruitment via
SDF-1alpha coacervate-laden PGS vascular grafts. Biomaterials.
2013;34(38):9877-9885.
23. Nieponice A, Soletti L, Guan J, et al. In vivo assessment of a tissue-engineered
vascular graft combining a biodegradable elastomeric scaffold and muscle-
derived stem cells in a rat model. Tissue engineering. Part A. 2010;16(4):1215-
1223.
24. Soletti L, Hong Y, Guan J, et al. A bilayered elastomeric scaffold for tissue
engineering of small diameter vascular grafts. Acta biomaterialia. 2010;6(1):110-
122.
25. Hoerstrup SP, Cummings Mrcs I, Lachat M, et al. Functional growth in tissue-
engineered living, vascular grafts: follow-up at 100 weeks in a large animal
model. Circulation. 2006;114(1 Suppl):I159-166.
26. Cummings I, George S, Kelm J, et al. Tissue-engineered vascular graft
remodeling in a growing lamb model: expression of matrix metalloproteinases.
European journal of cardio-thoracic surgery : official journal of the European
Association for Cardio-thoracic Surgery. 2012;41(1):167-172.
27. Schmedlen RH, Elbjeirami WM, Gobin AS, West JL. Tissue engineered small-
diameter vascular grafts. Clinics in Plastic Surgery.30(4):507-517.
28. Koch S, Flanagan TC, Sachweh JS, et al. Fibrin-polylactide-based tissue-
engineered vascular graft in the arterial circulation. Biomaterials.
2010;31(17):4731-4739.
29. O’Cearbhaill ED, Murphy M, Barry F, McHugh PE, Barron V. Behavior of Human
Mesenchymal Stem Cells in Fibrin-Based Vascular Tissue Engineering
Constructs. Annals of Biomedical Engineering. 2010;38(3):649-657.
30. Li Y, Meng H, Liu Y, Lee BP. Fibrin Gel as an Injectable Biodegradable Scaffold
and Cell Carrier for Tissue Engineering. The Scientific World Journal.
2015;2015:10.
31. Stegemann JP, Kaszuba SN, Rowe SL. Review: advances in vascular tissue
engineering using protein-based biomaterials. Tissue engineering. 2007;13:2601-
2613.
32. Iijima M, Aubin H, Steinbrink M, et al. Bio-active coating of decellularized
vascular grafts with a temperature-sensitive VEGF-conjugated hydrogel
accelerates autologous endothelialization in vivo. Journal of tissue engineering
and regenerative medicine. 2016.
33. Zisch AH, Lutolf MP, Ehrbar M, et al. Cell-demanded release of VEGF from
synthetic, biointeractive cell ingrowth matrices for vascularized tissue growth.
FASEB journal : official publication of the Federation of American Societies for
Experimental Biology. 2003;17(15):2260-2262.
34. Browning MB, Dempsey D, Guiza V, et al. Multilayer vascular grafts based on
collagen-mimetic proteins. Acta biomaterialia. 2012;8(3):1010-1021.
35. Madhavan K, Elliott WH, Bonani W, Monnet E, Tan W. Mechanical and
biocompatible characterizations of a readily available multilayer vascular graft.
Journal of biomedical materials research. Part B, Applied biomaterials.
2013;101(4):506-519.
36. Kuo KC, Lin RZ, Tien HW, et al. Bioengineering vascularized tissue constructs
using an injectable cell-laden enzymatically crosslinked collagen hydrogel
derived from dermal extracellular matrix. Acta biomaterialia. 2015;27:151-166.
37. Concheiro A, Alvarez-Lorenzo C. Chemically cross-linked and grafted
cyclodextrin hydrogels: from nanostructures to drug-eluting medical devices.
Advanced drug delivery reviews. 2013;65(9):1188-1203.
38. Syedain Z, Reimer J, Lahti M, et al. Tissue engineering of acellular vascular
grafts capable of somatic growth in young lambs. Nature Communications.
2016;7:12951.
39. Crapo PM, Gilbert TW, Badylak SF. An overview of tissue and whole organ
decellularization processes. Biomaterials. 2011;32(12):3233-3243.
40. Seifu DG, Purnama A, Mequanint K, Mantovani D. Small-diameter vascular
tissue engineering. Nat Rev Cardiol. 2013;10(7):410-421.
41. Campbell JH, Efendy JL, Campbell GR. Novel vascular graft grown within
recipient's own peritoneal cavity. Circulation research. 1999;85:1173-1178.
42. Hajiali H, Shahgasempour S, Naimi-Jamal MR, Peirovi H. Electrospun
PGA/gelatin nanofibrous scaffolds and their potential application in vascular
tissue engineering. International journal of nanomedicine. 2011;6:2133-2141.
43. Xie Y, Guan Y, Kim SH, King MW. The mechanical performance of weft-
knitted/electrospun bilayer small diameter vascular prostheses. Journal of the
Mechanical Behavior of Biomedical Materials. 2016;61:410-418.
44. Gong W, Lei D, Li S, et al. Hybrid small-diameter vascular grafts: Anti-expansion
effect of electrospun poly epsilon-caprolactone on heparin-coated decellularized
matrices. Biomaterials. 2016;76:359-370.
45. Takeuchi M, Kuratani T, Miyagawa S, et al. Tissue-engineered stent-graft
integrates with aortic wall by recruiting host tissue into graft scaffold. Journal of
Thoracic and Cardiovascular Surgery. 2014;148:1719-1725.
46. Mooney D, Vacanti JP. Tissue Engineering Using Cells and Synthetic Polymers.
1993;7:153-162.
47. Drilling S, Gaumer J, Lannutti J. Fabrication of burst pressure competent
vascular grafts via electrospinning: Effects of microstructure. Journal of
Biomedical Materials Research - Part A. 2009;88:923-934.
48. Hou Q, Grijpma DW, Feijen J. Porous polymeric structures for tissue engineering
prepared by a coagulation, compression moulding and salt leaching technique.
Biomaterials. 2003;24(11):1937-1947.
49. Kumar TR, Krishnan LK. A stable matrix for generation of tissue-engineered
nonthrombogenic vascular grafts. Tissue engineering. 2002;8(5):763-770.
50. Jeong SI, Kim SY, Cho SK, et al. Tissue-engineered vascular grafts composed of
marine collagen and PLGA fibers using pulsatile perfusion bioreactors.
Biomaterials. 2007;28(6):1115-1122.
51. Schoof H, Apel J, Heschel I, Rau G. Control of pore structure and size in freeze-
dried collagen sponges. Journal of biomedical materials research.
2001;58(4):352-357.
52. Kundu BSJ, Kundu SC. Biomaterial Scaffold Fabrication Techniques for Potential
Tissue Engineering Applications. In: Eberli D, ed. Tissue Engineering: InTech;
2010.
53. Gui L, Dash BC, Luo J, et al. Implantable tissue-engineered blood vessels from
human induced pluripotent stem cells. Biomaterials. 2016;102:120-129.
54. Im SH, Jung Y, Jang Y, Kim SH. Poly(L-lactic acid) scaffold with oriented micro-
valley surface and superior properties fabricated by solid-state drawing for blood-
contact biomaterials. Biofabrication. 2016;8.
55. Sugiura T, Tara S, Nakayama H, et al. Fast-degrading bioresorbable arterial
vascular graft with high cellular infiltration inhibits calcification of the graft. Journal
of vascular surgery. 2016:1-8.
56. Rapoport HS, Fish J, Basu J, et al. Construction of a tubular scaffold that mimics
J-shaped stress/strain mechanics using an innovative electrospinning technique.
Tissue engineering. Part C, Methods. 2012;18:567-574.
57. Villalona GA, Udelsman B, Duncan DR, et al. Cell-Seeding Techniques in
Vascular Tissue Engineering. Tissue Engineering. Part B, Reviews.
2010;16(3):341-350.
58. Pawlowski KJ, Rittgers SE, Schmidt SP, Bowlin GL. Endothelial cell seeding of
polymeric vascular grafts. Frontiers in bioscience : a journal and virtual library.
2004;9:1412-1421.
59. Salacinski HJ, Tiwari A, Hamilton G, Seifalian AM. Cellular engineering of
vascular bypass grafts: role of chemical coatings for enhancing endothelial cell
attachment. Medical & biological engineering & computing. 2001;39(6):609-618.
60. Hsu SH, Tsai IJ, Lin DJ, Chen DC. The effect of dynamic culture conditions on
endothelial cell seeding and retention on small diameter polyurethane vascular
grafts. Medical engineering & physics. 2005;27(3):267-272.
61. van Wachem PB, Stronck JW, Koers-Zuideveld R, Dijk F, Wildevuur CR.
Vacuum cell seeding: a new method for the fast application of an evenly
distributed cell layer on porous vascular grafts. Biomaterials. 1990;11(8):602-
606.
62. Bowlin GL, Meyer A, Fields C, et al. The persistence of electrostatically seeded
endothelial cells lining a small diameter expanded polytetrafluoroethylene
vascular graft. Journal of biomaterials applications. 2001;16(2):157-173.
63. Shimizu K, Ito A, Arinobe M, et al. Effective cell-seeding technique using
magnetite nanoparticles and magnetic force onto decellularized blood vessels for
vascular tissue engineering. Journal of bioscience and bioengineering.
2007;103(5):472-478.
64. Mann BK, Gobin AS, Tsai AT, Schmedlen RH, West JL. Smooth muscle cell
growth in photopolymerized hydrogels with cell adhesive and proteolytically
degradable domains: synthetic ECM analogs for tissue engineering.
Biomaterials. 2001;22(22):3045-3051.
65. Shimizu T, Yamato M, Kikuchi A, Okano T. Cell sheet engineering for myocardial
tissue reconstruction. Biomaterials. 2003;24(13):2309-2316.
66. Sodian R, Lemke T, Fritsche C, et al. Tissue-engineering bioreactors: a new
combined cell-seeding and perfusion system for vascular tissue engineering.
Tissue engineering. 2002;8(5):863-870.
67. Pashneh-Tala S, MacNeil S, Claeyssens F. The Tissue-Engineered Vascular
Graft—Past, Present, and Future. Tissue Engineering Part B: Reviews.
2015;22:ten.teb.2015.0100.
68. Wang L, Hu J, Sorek CE, Chen EY, Ma PX, Yang B. Fabrication of tissue-
engineered vascular grafts with stem cells and stem cell-derived vascular cells.
Expert opinion on biological therapy. 2016;16:317-330.
69. Cho S-W, Lim SH, Kim I-K, et al. Small-Diameter Blood Vessels Engineered With
Bone Marrow–Derived Cells. Annals of Surgery. 2005;241(3):506-515.
70. Poh M, Boyer M, Solan A, et al. Blood vessels engineered from human cells.
Lancet (London, England). 2005;365(9477):2122-2124. * This paper showed
that human telomerase expression led to the successful culture of
engineered blood vessels.
71. Wystrychowski W, McAllister TN, Zagalski K, Dusserre N, Cierpka L, L'Heureux
N. First human use of an allogeneic tissue-engineered vascular graft for
hemodialysis access. Journal of vascular surgery. 2014;60(5):1353-1357.
72. Asahara T, Murohara T, Sullivan A, et al. Isolation of putative progenitor
endothelial cells for angiogenesis. Science (New York, N.Y.).
1997;275(5302):964-967.
73. Shirota T, He H, Yasui H, Matsuda T. Human endothelial progenitor cell-seeded
hybrid graft: proliferative and antithrombogenic potentials in vitro and fabrication
processing. Tissue engineering. 2003;9(1):127-136.
74. Brandes RP, Ushio-Fukai M. Endothelial progenitor cells=EPC=elemental
pernicious complexity. Antioxidants & redox signaling. 2011;15(4):911-914.
75. Krawiec JT, Liao H-T, Kwan LL, et al. Evaluation of the stromal vascular fraction
of adipose tissue as the basis for a stem cell-based tissue-engineered vascular
graft. Journal of vascular surgery. 2016:1-9.
76. Mirensky TL, Hibino N, Sawh-Martinez RF, et al. Tissue-engineered vascular
grafts: does cell seeding matter? Journal of pediatric surgery. 2010;45(6):1299-
1305.
77. Hibino N, Shin'oka T, Matsumura G, Ikada Y, Kurosawa H. The tissue-
engineered vascular graft using bone marrow without culture. The Journal of
thoracic and cardiovascular surgery. 2005;129(5):1064-1070.
78. Matsumura G, Miyagawa-Tomita S, Shin'oka T, Ikada Y, Kurosawa H. First
evidence that bone marrow cells contribute to the construction of tissue-
engineered vascular autografts in vivo. Circulation. 2003;108(14):1729-1734.
79. Heydarkhan-Hagvall S, Schenke-Layland K, Yang JQ, et al. Human adipose
stem cells: a potential cell source for cardiovascular tissue engineering. Cells,
tissues, organs. 2008;187(4):263-274.
80. Peng HF, Liu JY, Andreadis ST, Swartz DD. Hair follicle-derived smooth muscle
cells and small intestinal submucosa for engineering mechanically robust and
vasoreactive vascular media. Tissue engineering. Part A. 2011;17(7-8):981-990.
81. Krawiec JT, Vorp DA. Adult stem cell-based tissue engineered blood vessels: A
review. Biomaterials. 2012;33:3388-3400.
82. Sundaram S, Echter A, Sivarapatna A, Qiu C, Niklason L. Small-diameter
vascular graft engineered using human embryonic stem cell-derived
mesenchymal cells. Tissue engineering. Part A. 2014;20:740-750.
83. Takahashi K, Yamanaka S. Induction of pluripotent stem cells from mouse
embryonic and adult fibroblast cultures by defined factors. Cell. 2006;126(4):663-
676.
84. Dash BC, Levi K, Schwan J, et al. Tissue-Engineered Vascular Rings from
Human iPSC-Derived Smooth Muscle Cells. Stem cell reports. 2016;7(1):19-28.
85. Sundaram S, One J, Siewert J, et al. Tissue-engineered vascular grafts created
from human induced pluripotent stem cells. Stem cells translational medicine.
2014;3(12):1535-1543.
86. Hibino N, Duncan DR, Nalbandian A, et al. Evaluation of the use of an induced
puripotent stem cell sheet for the construction of tissue-engineered vascular
grafts. Journal of Thoracic and Cardiovascular Surgery. 2012;143:696-703.
87. Lee Y-U, Mahler N, Best CA, et al. Rational design of an improved tissue-
engineered vascular graft: determining the optimal cell dose and incubation time.
Regenerative Medicine. 2016;11(2):159-167.
88. Lee MH, Kwon B-j, Koo M-A, Jang EH, Seon GM, Park J-C. Exovascular
application of epigallocatechin-3-O-gallate-releasing electrospun poly(L-lactide
glycolic acid) fiber sheets to reduce intimal hyperplasia in injured abdominal
aorta. Biomedical materials (Bristol, England). 2015;10:55010.
89. Centola M, Rainer A, Spadaccio C, De Porcellinis S, Genovese JA, Trombetta M.
Combining electrospinning and fused deposition modeling for the fabrication of a
hybrid vascular graft. Biofabrication. 2010;2:014102.
90. Spadaccio C, Rainer A, Centola M, et al. Heparin-releasing scaffold for stem
cells: a differentiating device for vascular aims. Regenerative Medicine.
2010;5:645-657.
91. Zou J, Zhang X, Yang H, Zhu Y, Ma H, Wang S. Rapamycin-loaded
nanoparticles for inhibition of neointimal hyperplasia in experimental vein grafts.
Annals of Vascular Surgery. 2011;25:538-546.
92. Duncan DR, Chen PY, Patterson JT, et al. TGFβR1 inhibition blocks the
formation of stenosis in tissue-engineered vascular grafts. Journal of the
American College of Cardiology. 2015;65:512-514.
93. Dimitrievska S, Cai C, Weyers A, et al. Click-coated, heparinized, decellularized
vascular grafts. Acta biomaterialia. 2015;13:177-187.
94. Dahl SLM, Blum JL, Niklason LE. Bioengineered Vascular Grafts: Can We Make
Them Off-the-Shelf? Trends in Cardiovascular Medicine. 2011;21:83-89.
95. Hibino N, Nalbandian A, Devine L, et al. Comparison of Human Bone Marrow
Mononuclear Cell Isolation Methods for Creating Tissue-Engineered Vascular
Grafts: Novel Filter System Versus Traditional Density Centrifugation Method.
Tissue Engineering Part C: Methods. 2011;17:993-998.
96. Dahl SLM, Kypson AP, Lawson JH, et al. Readily Available Tissue-Engineered
Vascular Grafts. Science Translational Medicine. 2011;3:68ra69-68ra69.
97. Quint C, Arief M, Muto A, Dardik A, Niklason LE. Allogeneic human tissue-
engineered blood vessel. Journal of vascular surgery. 2012;55:790-798.
98. Shin'oka T, Matsumura G, Hibino N, et al. Midterm clinical result of tissue-
engineered vascular autografts seeded with autologous bone marrow cells.
Journal of Thoracic and Cardiovascular Surgery. 2005;129.
99. Shinoka T, Breuer C. Tissue-engineered blood vessels in pediatric cardiac
surgery. The Yale journal of biology and medicine. 2008;81:161-166.
100. Hibino N, McGillicuddy E, Matsumura G, et al. Late-term results of tissue-
engineered vascular grafts in humans. Journal of Thoracic and Cardiovascular
Surgery. 2010;139:431-436.e432. * This paper discussed the late-term results
of patients, who underwent implantation of TEVGs as extracardiac
cavopulmonary conduits.
101. Lawson JH, Glickman MH, Ilzecki M, et al. Bioengineered human acellular
vessels for dialysis access in patients with end-stage renal disease: Two phase 2
single-arm trials. The Lancet. 2016;387:2026-2034. * This paper tested
bioengineered human acellular vessels as conduits for hemodialysis
assess in a clinical trial.
102. Bockeria LA, Svanidze O, Kim A, et al. Total Cavo-Pulmonary Connection with a
New Bio-Absorbable Vascular Graft First Clinical Experience. The Journal of
thoracic and cardiovascular surgery. 2017;0.
103. McAllister TN, Maruszewski M, Garrido SA, et al. Effectiveness of haemodialysis
access with an autologous tissue-engineered vascular graft: a multicentre cohort
study. Lancet (London, England). 2009;373(9673):1440-1446. * This paper
reported the clinical trial results of completely biological and autologous
TEVGs implanted for hemodialysis assess.
104. Kraak RP, Grundeken MJ, Koch KT, de Winter RJ, Wykrzykowska JJ.
Bioresorbable scaffolds for the treatment of coronary artery disease: current
status and future perspective. Expert Rev Med Devices. 2014;11:467-480.
105. Roh JD, Sawh-Martinez R, Brennan MP, et al. Tissue-engineered vascular grafts
transform into mature blood vessels via an inflammation-mediated process of
vascular remodeling. Proceedings of the National Academy of Sciences.
2010;107(10):4669-4674.
106. Hibino N, Mejias D, Pietris N, et al. The innate immune system contributes to
tissue-engineered vascular graft performance. The FASEB Journal.
2015;29(6):2431-2438.
107. !!! INVALID CITATION !!! 107.
108. G N, Tan A, Gundogan B, et al. Tissue engineering vascular grafts a fortiori:
looking back and going forward. Expert opinion on biological therapy.
2015;15:231-244.
109. Rocco KA, Maxfield MW, Best CA, Dean EW, Breuer CK. In vivo applications of
electrospun tissue-engineered vascular grafts: a review. Tissue engineering. Part
B, Reviews. 2014;20:628-640.
110. Fukunishi T, Shoji T, Shinoka T. 18. Nanofiber composites in vascular tissue
engineering. Nanofiber Composite Materials for Biomedical Applications. 2016:1-
31.
111. Jaspan VN, Hines GL. The Current Status of Tissue-Engineered Vascular Grafts.
Cardiology in Review. 2015;23:236-239.
112. Gökçinar-Yagci B, Uçkan-Çetinkaya D, Çelebi-Saltik B. Pericytes: Properties,
Functions and Applications in Tissue Engineering. Stem Cell Reviews and
Reports. 2015;11:549-559.
113. Fukunishi T, Best CA, Sugiura T, et al. Preclinical study of patient-specific cell-
free nanofiber tissue-engineered vascular grafts using 3-dimensional printing in a
sheep model. The Journal of thoracic and cardiovascular surgery. 2016.