Title : The pomegranate theory: a systematic review and meta-analysis on decellularization techniques for tissue-engineered aortic scaffolds development
Abstract:
Key Words: Decellularisation, Aortic grafts, Extracellular matrix (ECM), Sodium dodecyl sulfate (SDS), Sonication, High hydrostatic pressure (HHP), Biocompatibility Background: Decellularised aortic grafts are a promising alternative to synthetic and biological vascular substitutes used in endovascular aortic repair (EVAR), o?ering the potential for improved biocompatibility, reduced immunogenicity, and enhanced tissue integration. However, the lack of a standardised decellularisation protocol and variability in reported outcomes necessitate a systematic evaluation of existing techniques. Objective: This review aimed to compare the impact of di?erent decellularisation methods on extracellular matrix (ECM) preservation, biomechanical performance, and overall suitability of aortic sca?olds for vascular reconstruction, with particular focus on emerging sonication-assisted approaches. Methods: A systematic review was conducted in accordance with PRISMA guidelines and registered on the Open Science Framework. PubMed, Scopus, EMBASE, and IEEE Xplore were searched from 2000 to March 2025. Eligible studies evaluated decellularisation of healthy aortic tissue and reported sca?old-relevant outcomes, including cellular removal and/or biomechanical integrity. Data extraction and quality assessment were performed independently by multiple reviewers. Results: A total of 29 preclinical studies were included, predominantly in vitro using porcine aortic tissue. Four decellularisation strategies were identified: chemical, enzymatic, physical, and combination methods. Chemical approaches, particularly sodium dodecyl sulfate (SDS), achieved the most e?ective cellular removal, reducing DNA to as low as 27 ng/mg. However, SDS compromised extracellular matrix integrity and mechanical performance, reducing burst pressure by ~38% and compliance by 15–20%. In contrast, enzymatic and physical methods, including high hydrostatic pressure (HHP), better preserved ECM structure and tensile strength, with HHP reaching ~5.0 N/mm² versus ~4.1 N/mm² in native tissue and ~0.5 µg/mg residual DNA. Combination protocols produced the most balanced outcomes but required longer processing times (>100 hours). Sonication improved detergent penetration and reduced DNA to 0.3–0.6 µg/mg. In vivo studies (n = 6) showed favourable early biocompatibility but limited long-term data. Conclusion: Decellularisation technique strongly influences sca?old performance. While SDS is e?ective for cell removal, it compromises ECM integrity. Combination methods, particularly those incorporating sonication or HHP, show the most promise. However, lack of standardisation and limited long-term evidence remain key barriers to clinical translation.
