Porcine carotid artery replacement with biodegradable electrospun poly-e-caprolactone vascular prosthesis Wojciech Mrówczyński, MD, PhD, Damiano Mugnai,

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Porcine carotid artery replacement with biodegradable electrospun poly-e-caprolactone vascular prosthesis Wojciech Mrówczyński, MD, PhD, Damiano Mugnai, MD, FEBVS, Sarra de Valence, PhD, Jean-Christophe Tille, MD, PhD, Ebrahim Khabiri, MD, Mustafa Cikirikcioglu, MD, PhD, FETCS, Michael Möller, PhD, Beat H. Walpoth, MD, FAHA Journal of Vascular Surgery Volume 59, Issue 1, Pages 210-219 (January 2014) DOI: 10.1016/j.jvs.2013.03.004 Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 1 Biodegradable poly-ε-caprolactone (PCL) vascular graft. Graft characteristics: inner diameter, 4 mm; length, 80 mm; wall thickness, 500 μm; mean fiber diameter of 2.2 ± 0.6 μm; porosity, 80%; maximum tensile stress of 4.8 MPa, and maximum tensile strain of 600%. Insert: scanning electron microscope (SEM) picture (magnification, ×90) of graft transverse cross-section and external surface. Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 2 Implantation of poly-ε-caprolactone (PCL) prosthesis. A, Native porcine common carotid artery after surgical preparation (note vagus nerve indicated by the arrow). B, Native common carotid artery is cross-clamped proximally as well as distally and divided. The graft is beveled at the proximal end before construction of the end-to-end anastomosis. The distal part will be beveled just before performing the anastomosis. C, PCL graft is implanted in carotid position with the use of interrupted nonresorbable polyprolpylene 7-0 sutures. *Proximal side. Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 3 Angiographic study of the implanted grafts after 4 weeks (antero-posterior projection). A, Patent poly-ε-caprolactone (PCL) graft. B, Patent expanded polytetrafluoroethylene (ePTFE) graft. No anastomotic stenosis or aneurysm formation visible. *Proximal anastomosis; #distal anastomosis. Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 4 Intraoperative physiological assessment of studied vascular grafts. Blood flow through the carotid artery measured with ultrasound transit time flow (TTF) method. Intergroup comparisons: *, **, *** - all statistically nonsignificant. Intragroup, repeated measure comparisons: poly-ε-caprolactone (PCL) graft: #-#, ##-## - both statistically nonsignificant; expanded polytetrafluoroethylene (ePTFE) graft: $-$, $$-$$ - both statistically nonsignificant. Occluded grafts excluded from analysis. Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 5 Percutaneous ultrasound study of implanted vascular grafts. A, Maximal flow velocity through the carotid artery measured with percutaneous Doppler ultrasound. Intergroup comparisons: *, **, *** - all statistically nonsignificant. Intragroup, repeated measure comparisons: poly-ε-caprolactone (PCL) graft: #-#, ##-## - both statistically nonsignificant; expanded polytetrafluoroethylene (ePTFE) graft: $-$, $$-$$ - both statistically nonsignificant. B, Carotid artery internal diastolic diameter over time. Intergroup comparisons: *, **, *** - all statistically nonsignificant. Intragroup, repeated measure comparisons: PCL graft: #-#, ##-## - both statistically nonsignificant; ePTFE graft: $-$, $$-$$ - both statistically nonsignificant. Occluded grafts excluded from analysis. Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 6 Morphometric analyses of the grafts after 4 weeks: endothelial coverage, neointimal hyperplasia coverage, thrombus coverage, and percent transmural cellular ingrowth according to graft type. A, Percent of endothelial coverage, significant intergroup difference (∗P = .008). B, Percent of neointimal hyperplasia coverage (P = NS). C, Percent of thrombus/microthrombus coverage (P = NS). D, Percent of transmural cellular ingrowth (∗P = .001). Occluded grafts excluded from the analysis. ePTFE, Expanded polytetrafluoroethylene; PCL, poly-ε-caprolactone. Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 7 Histopathological findings according to vascular implant type. A, C, E, G, Poly-ε-caprolactone (PCL). B, D, F, H, Expanded polytetrafluoroethylene (ePTFE). A and B, CD31 immunostaining shows endoluminal endothelial coverage (arrow) that was more complete in PCL (A) grafts than in ePTFE (B) implants (magnification, 400×). C and D, Neointimal hyperplasia (arrows) was present in both types of implants (magnification, 200×). E and F, Multiple microthrombi (arrow) were present in both PCL and ePTFE vascular grafts (magnification, 20×). G and H, Neovessels in the graft (arrows) were more abundant in PCL implants in comparison to ePTFE prostheses, where only single capillaries were invading superficially the adventitial surface of the graft (magnification, 20×). #Lumen of the prosthesis; ^Adventitial side of the prosthesis. Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 8 Scanning electron microscope (SEM) picture of poly-ε-caprolactone (PCL) vascular grafts. A, View of the endoluminal surface of nonimplanted PCL (magnification, 180×). B, Complete endothelialization of PCL graft (magnification, 760×). C, Cross-section of PCL implant (*), lumen of the graft (#). Protein and endothelial coverage are visible on the endoluminal surface (magnification, 760×). D, Presence of the microthrombus on the endoluminal surface of the neoendothelialized PCL graft (magnification, 750×). E, Proximal anastomosis area of PCL graft. l, Longitudinal disposition of the native carotid artery endothelium; p, perpendicular neoendothelium. *Nonendothelialized zone (magnification, 70×). F, PCL graft transition zone between endothelialized zone and protein-covered area. ∗Nonendothelialized zone (magnification, 390×). Journal of Vascular Surgery 2014 59, 210-219DOI: (10.1016/j.jvs.2013.03.004) Copyright © 2014 Society for Vascular Surgery Terms and Conditions