Editorial on the Research Topic
New discoveries in bioengineering applied to vascular surgery
1.
Introduction
The field of vascular medicine has witnessed the fifth cardiovascular revolution (1),
thanks to the convergence and the synergistic relationship between vascular biomaterials,
synthetic vascular neuronal networks, and artificial intelligence.
Healthcare has long been the beneficiary of technological advancements, with innovations
consistently pushing the boundaries of what's possible in medical science. Among these
remarkable developments, vascular bioengineering stands out as a beacon of hope, poised
to revolutionize the treatment of cardiovascular diseases and usher in a new era of
personalized medicine. This field has made substantial progress through the convergence
of biology, engineering, and medical science, offering glimpses into a future where
regenerative therapies, artificial organs, and minimally invasive procedures are commonplace.
These innovations have revolutionized the diagnosis and treatment of vascular diseases,
paving the way for precision medicine tailored to individual patient needs (2).
1.1.
The burden of cardiovascular diseases
Cardiovascular diseases (CVDs) represent a significant global health challenge, with
conditions like Atherosclerosis, aneurysms, and ischemic disorders ranking among the
leading causes of mortality. These diseases often necessitate invasive and high-risk
interventions, such as open-heart surgeries or the implantation of synthetic materials.
However, these conventional approaches are plagued by inherent issues, including the
risk of rejection, limited durability, and the need for lifelong medication. Vascular
bioengineering emerges as a promising solution to these long-standing problems. Vascular
diseases, including atherosclerosis, aneurysms, and ischemic conditions, are among
the leading causes of mortality worldwide. Traditional treatment approaches often
involve open surgeries or the implantation of synthetic materials, which present various
challenges, such as the risk of rejection, limited durability, and the need for lifelong
medication. Vessel characteristics vary by size, and the bioengineering of human conduits
must adjust to these requirements: the primary role and, therefore, the anatomic and
biochemical design of large vessels is in the efficient transport of blood while vessels
of smaller diameter gradually switch to performing more exchange functions in lower
pressure, slower flow environment.
Repair, graft replacement, and reconstruction are the challenges for the expected
benefits of bioengineering human tissues and blood vessels because the number of patients
affected by peripheral arterial disease (PAD), requiring peripheral surgery, is steadily
growing. PAD and vascular injuries, including civilian and military traumatic injuries,
represent another area of the critical need for replacement vessels (3).
Vascular replacements started with autologous saphenous vein graft described in 1949,
and in the following years prostethic grafts have been developed (4).
1.2.
The promise of vascular bioengineering
1.2.1.
Regenerative therapies
One of the most exciting prospects in vascular bioengineering is the development of
regenerative therapies. Stem cell research, for instance, has shown tremendous potential
in growing functional blood vessels that can be tailored to individual patient needs.
These regenerative approaches promise to replace damaged or diseased vessels with
biologically compatible constructs, reducing the risks associated with synthetic materials.
1.2.2.
Artificial organs
Vascular bioengineering also holds the key to creating artificial organs that mimic
the complex functions of the human circulatory system. These bioengineered organs,
like artificial hearts and blood vessels, can potentially provide patients with life-saving
solutions, reducing the waiting times and complications associated with organ transplantation.
1.2.3.
Minimally invasive procedures
Traditional surgical interventions often entail significant trauma and extended recovery
periods. Vascular bioengineering, however, is driving the development of minimally
invasive procedures. Techniques like catheter-based treatments and drug-eluting stents
are becoming more sophisticated, allowing precise interventions with reduced patient
discomfort and recovery times.
1.2.4.
Personalized medicine
One of the most profound impacts of vascular bioengineering is the move towards personalized
medicine. By leveraging advancements in genomics and biotechnology, healthcare providers
can tailor treatments to each patient's unique genetic makeup, optimizing outcomes
and minimizing adverse effects.
2.
Vascular biomaterials
Vascular biomaterials are engineered materials designed for compatibility with the
human vascular system.
They have played a pivotal role in the development of advanced vascular therapies.
These biomaterials can be divided into two categories: biological and synthetic.
Biological biomaterials, such as tissue-engineered grafts and decellularized matrices,
offer the advantage of biocompatibility. They can support cell growth and tissue regeneration,
making them valuable for repairing damaged vessels. On the other hand, synthetic biomaterials,
like biodegradable polymers, provide mechanical strength and controlled degradation
rates. They are often used for stent coatings, promoting healing while preventing
restenosis.
3.
Synthetic vascular neuronal networks
Synthetic vascular neuronal networks, a relatively new concept, involve creating artificial
neural networks that mimic the autonomic nervous system's control over vascular functions.
These networks integrate with the vascular system to monitor and regulate real-time
blood flow, vasodilation, and vasoconstriction. They are particularly beneficial in
managing conditions like hypertension and vascular insufficiencies.
These networks are designed to adapt to individual patient needs, ensuring precise
control over vascular parameters. AI algorithms play a crucial role in optimizing
the performance of these synthetic networks by continuously analyzing data from digital
twins and sensors and then making necessary adjustments.
4.
Artificial intelligence
Artificial Intelligence (AI) has emerged as a game-changer in the field of vascular
medicine. Machine learning algorithms can process vast amounts of patient data, including
medical records, imaging studies, and genetic information, to identify patterns and
predict disease risks. This enables early diagnosis and personalized treatment plans.
AI-driven image analysis, such as in medical imaging and pathology, enhances the accuracy
of vascular disease diagnosis. Moreover, predictive analytics help forecast disease
progression, allowing for proactive interventions. AI-driven robotics and surgical
assistance also contribute to the precision and safety of vascular procedures.
5.
Precision vascular medicine
The synergy of vascular biomaterials, synthetic neuronal networks, and AI culminates
in precision vascular medicine. Tailored treatment plans are created based on individual
patient profiles, optimizing therapeutic outcomes while minimizing side effects.
Here are some key benefits:
1.
Personalized Drug Delivery: Biomaterials can be used as drug carriers, releasing medications
at specific locations within the vascular system, guided by synthetic networks and
AI algorithms.
2.
Targeted Therapies: AI analyzes patient data to identify optimal treatment strategies,
considering genetic factors, lifestyle, and disease progression, resulting in targeted
therapies.
3.
Minimized Risks: Real-time monitoring and control by synthetic networks reduce procedural
risks and enhance the safety of vascular interventions.
4.
Improved Outcomes: Early diagnosis, precise treatment, and continuous monitoring lead
to improved patient outcomes and quality of life.
Vascular grafts are usually made of synthetic polymers, animal and cadaveric tissues,
or autologous and used with well-characterized outcomes, leaving areas of unmet need
for the patients in terms of durability and long-term patency, susceptibility to infection,
immunogenicity, inflammation, and mechanical failure. Vascular bioengineering aims
to overcome these hurdles by leveraging cutting-edge techniques to create functional,
biocompatible vascular replacements. One of the most promising areas within vascular
bioengineering is tissue engineering.
One of the most significant challenges to the deployment of vascular grafts is their
adoption by the host and their ability to remodel into new tissues. Several research
strategies have been implemented to reduce infection rates, promote endothelialization,
and inhibit inflammation. While some histological data demonstrate partial recellularization
of xenografts, many clinical reports of explanted specimens provide evidence of inflammation,
calcification, and neointima formation without cellularization of the implanted ECM
(5).
Another facet of vascular bioengineering focuses on developing advanced prosthetics
and implants.
Innovations such as bioresorbable stents that gradually dissolve after serving their
purpose (6) innovative implants that monitor and respond to physiological changes,
and tissue-engineered heart valves that mimic natural function are reshaping the landscape
of cardiovascular interventions.
Minimally invasive procedures have become the cornerstone of modern medicine, offering
reduced risks, shorter recovery times, and improved patient comfort. Vascular bioengineering
contributes to this trend by creating catheters, delivery systems, and imaging techniques
that enable precise interventions through small incisions. These advancements are
extending the benefits of vascular treatments to a broader range of patients who may
not have been candidates for invasive surgeries.
While the progress in vascular bioengineering is undeniably promising, challenges
remain.
Ensuring the long-term durability and compatibility of engineered tissues and materials,
addressing potential immune responses, and navigating regulatory pathways are all
critical considerations. Graft failures due to loss of integrity, inflammation, and
fibrosis have repeatedly been observed, often in environments experiencing mechanical
stress or high pressures. Autologous grafts remain the preferred option for vessel
replacement or repair, eliminating the risk of rejection presented by xenografts and
allogenic vein grafts, resisting infection better than synthetic materials, and displaying
mechanical properties most closely aligned with the conduit to be replaced. However,
they face limitations concerning availability, risk of thrombosis due to damaged endothelium,
intimal hyperplasia, and accelerated atherosclerosis. New research avenues focus on
generating innovative materials that would decrease the risk of infection, thrombosis,
and rejection and either undergo remodeling by the host or induce regeneration and
repair of the host's tissues. Other two topics are relevant in the evolution of the
vascular field: the use of robotics and endovascular devices and their relationship
to the arterial wall.
The introduction of robotics represented another significant step forward for different
surgical specialties, facilitating and improving the performance of minimally invasive
surgery. Robot-assisted surgery has been brought into the area of vascular surgery
to enhance laparoscopic vascular and endovascular skills, such as a relatively tricky
manipulation of instruments and long suturing times for anastomoses and clamping of
the aorta or pelvic arteries (7). It is well documented in the literature despite
none of the systems described above having been employed on a widespread basis. The
surgeon's movements are down-scaled into fine gestures, physiological tremor is eliminated,
and the visualization is improved, thus simplifying those actions unachievable in
traditional surgery. High costs and the lack of approval for use in the vascular field
have contributed to their low popularity. However, concerns about addressing higher
costs in favor of substantial health benefits for medical staff and patients should
be considered.
The second aspect is critical of endovascular procedures. Endovascular procedures
aim to create structural support to the arterial wall for a new path for the blood
into the arteries, excluding aneurysms by the risk of enlargement and rupture or creating
a new way in case of previous arterial occlusion.
Especially about the aneurysm treatment, the relationship between the endograft and
the arterial wall can be understood in terms of the following key points: sealing
and anchoring; integration and healing (it helps improve the long-term stability of
the repair), minimization of blood flow (endograft alters the blood flow dynamics
within the artery) and potential complications (treatment of certain vascular conditions,
there can be complications related to the relationship between the graft and the arterial
wall). Careful patient selection, proper sizing and positioning of the endograft,
and regular follow-up are essential to minimize these risks.
The ideal design of the aortic endograft should resemble the native aorta in terms
of its flexibility and hemodynamic impedance. The stent-graft polymers should be lightweight
but strong, resilient, and capable of withstanding the impact of normal pulsatile
high-flow arterial blood pressure. There is increasing evidence of adverse hemodynamic
alteration post-TEVAR/EVAR. Interventionalists must respect the aorta as an active
organ, not a mere conduit. The best solution in the short term could be to reduce
the stented length of the aorta while, in the longer term, encouraging continuous
improvement in stent-graft materials and design. The relationship between a vascular
endograft and the arterial wall is a complex interplay of biomechanical factors, healing
processes, and medical considerations. The success of endovascular procedures relies
on the proper selection and placement of the endograft, as well as careful management
and monitoring to ensure optimal patient outcomes.
The intelligent endoprosthesis will adapt to prevent tissue ingrowth into its’ microstructure,
preventing rigidity and maintaining distensibility. Therefore, the Smart endoprosthesis
will retain the ability to expand in systole and collapse in diastole. After implantation,
it returns the elastic recoil to the heart, creating an almost standard aortic flow
curve (8).
Vascular bioengineering represents a transformative force in cardiovascular medicine,
offering solutions once confined to science fiction. As researchers push the boundaries
of knowledge and technology, we can anticipate a future where vascular diseases are
treated with unprecedented precision, patients experience an improved quality of life,
and healthcare becomes increasingly personalized.
The potential to replace damaged vessels with bioengineered constructs, create artificial
organs, and perform minimally invasive procedures heralds a brighter and healthier
future for individuals affected by cardiovascular diseases. Through the intersection
of biology, engineering, and medical science, vascular bioengineering is paving the
way for a healthcare landscape that is more effective, patient-centered, and hopeful.
6.
Conclusion
The convergence of vascular biomaterials, synthetic vascular neuronal networks, and
artificial intelligence have ushered in a new era of precision vascular medicine.
Vascular bioengineering is poised to reshape the landscape of cardiovascular medicine,
offering solutions that were once confined to science fiction. We anticipate a future
where vascular diseases are treated with precision, patients experience improved quality
of life, and healthcare becomes increasingly personalized.
This innovative approach offers personalized solutions for patients with vascular
diseases, enhancing diagnostic accuracy and treatment efficacy. As these technologies
continue to advance, the future of vascular healthcare promises even more remarkable
breakthroughs, ultimately improving the lives of countless individuals suffering from
vascular conditions.