Biostability and blood-contacting properties of sulfonate grafted polyurethane and Biomer

Sulfonate-containing polyurethanes were evaluated for in vivo biodegradation using subcutaneously implanted tensile bars. In addition, these anionically charged polyurethanes were evaluated for in vivo activation of human complement C3a and ex vivo platelet deposition in arteriovenouslyshunted canines. The sulfonate derivatized polymers included laboratory synthesized polyurethane and Biomer. Other polymers used for references included Intramedic^TM polyethylene, Silastic^TM and a poly(ethylene oxide) based polyurethane. The biodegradation results indicated that Biomer and the laboratory sulfonated Biomer (both manufactured with stabilizers), remained mechanically stable, retaining both tensile strength and elasticity after 4 weeks of subcutaneous implantation. The unstabilized polyurethanes (with or without sulfonation), however, showed marked cracking and a loss of mechanical properties after the same period of subcutaneous implantation. Sulfonated polyurethanes depressed human complement C3a activation in plasma, as indicated by decreased levels of anaphylatoxin production. The results of canine ex vivo blood contacting experiments were conducted in both an acute and chronic model and demonstrated decreased platelet deposition and activation for the sulfonated polyurethanes.     

Physical and blood contacting characteristics of propyl sulphonate grafted Biomer

Propyl sulphonate groups were grafted on to the backbone of Biomer, a polyetherurethaneurea, in an attempt to improve its blood-contacting properties. The bulk, surface and blood-contacting properties of this series of sulphonated polymers were evaluated. Differential scanning calorimetry and dynamic mechanical analysis indicated that propyl sulphonate incorporation increased the microphase separation of the polymers. The ultimate tensile strength was also increased with sulphonation at the expense of the polymer's extensibility. Dynamic contact angle analysis showed that, in water, the sulphonated Biomer surfaces were more polar than the Biomer sample indicating the propyl sulphonate groups were enriched at the surface. Canine ex vivo blood-contacting results showed that the incorporation of propyl sulphonate groups dramatically reduced the number and activation of platelets adherent to the polymer surface. In addition, fibrinogen deposition increased with increasing sulphonate content, despite the low level of platelet activation.     

Properties and biological interactions of polyurethane anionomers: effect of sulfonate incorporation

In order to investigate the factors affecting the interaction of polyurethanes and blood, a series of poly(tetramethylene oxide)-based polyurethane block copolymers was synthesized with systematically varying levels of ion incorporation in the hard segment block. A bimolecular nucleophilic substitution reaction was used to replace up to 20% of the urethane hydrogens with propyl sulfonate groups. Bulk and surface characterization was performed, and a canine ex vivo arteriovenous shunt was used to monitor initial platelet and fibrinogen deposition on these surfaces. The microphase separation and bulk physical properties were found to vary with ionic content. Surface analysis using both in vacuo (ESCA) and water-equilibrated (contact angle) methods indicated that these polymers, and especially the highly sulfonated materials, could rearrange to minimize their interfacial tension, depending on the contacting environment. Platelet deposition onto these materials decreased as the level of sulfonation increased, with the highly sulfonated polymer showing substantially less platelet spreading and activation than previously seen in the same experiment with other polymers.     

Series shunt evaluation of polyurethane vascular graft materials in chronically AV-shunted canines

Well characterized, laboratory-synthesized polymeric materials which have been extensively tested for biocompatibility via initial platelet and protein deposition in an acute ex vivo canine model were placed as interpositional series shunts in canines with chronically implanted iliac arteriovenous shunts ex vivo. Platelet deposition was measured on a base polyurethane block copolymer, a sulfonated ionic derivative, an alkyl grafted (C18) derivative, Biomer, polyethylene, and polydimethylsiloxane for 24 h using radiolabeled platelets. Platelet survival and in vitro aggregation were determined to investigate the effects of the shunting procedure on experimental animals. The viability of adopting a chronic arteriovenous (iliac) shunted canine model for use with series shunts to evaluate polyurethanes having applications as materials in vascular graft construction was investigated and the results compared with acute model data.     

Negative cilia concept for thromboresistance: synergistic effect of PEO and sulfonate groups grafted onto polyurethanes

In order to investigate the interaction between various sulfonated polyurethanes (PUs) and blood, a commercial PU surface was chemically modified by poly(ethylene oxide) (PEO), dodecanediol(DDO), and propane sultone to give hydrophilic, hydrophobic, and negative sulfonated surfaces, respectively. The blood compatibility of modified PUs was evaluated by an in vitro platelet adhesion test, activated partial thromboplastin time (APTT), and prothrombin time (PT) measurements as well as an ex vivo rabbit A-A shunt method. In the platelet adhesion test, the hydrophilic PEO grafted PUs showed less platelet adhesion than untreated PU and hydrophobic DDO grafted PU. Sulfonated PU-PEO exhibited a lower degree of adhesion and shape change of platelet. The APTT and PT, especially APTT, of the sulfonated PUs were extended, whereas those of PU-PEO and PU-DDO did not show any significant change compared with untreated PU. Meanwhile, in the ex vivo experiment, hydrophilic PEO grafted PUs showed longer occlusion times than untreated PU or hydrophobic DDO grafted PU. In addition, the incorporation of SO3 groups at the end of PU-DDO and PU-PEO, particularly PU-PEO-SO3, exhibited an enormous prolongation in occlusion time, indicating a synergistic effect of the hydrophilic PEO and the negative SO3 groups on thromboresistance. These occlusion times corresponded well to in vitro evaluation results: the less adhesion and shape change of platelet and the longer APTT and PT, the more extended the ex vivo occlusion time.     

Physical and blood-contacting properties of polyurethanes based on a sulfonic acid-containing diol chain extender.

Polyurethanes chain extended with N,N-bis (2-hydroxyethyl)-2-aminoethane-sulfonic acid (BES) were synthesized. The effect of the sulfonic acid group on the polymers' bulk, surface, and blood-contacting properties was evaluated by comparing the BES-based polymers with polyurethanes based on N-ethyldiethanolamine (EDEA). In addition, the effect of soft-segment polarity was addressed by comparing polyurethanes based on polytetramethylene oxide (PTMO) (MW = 1000) with polymers based on polyethylene oxide (PEO) (MW = 1000). The EDEA control samples had physical properties similar to a viscous fluid. The presence of the sulfonic acid group dramatically enhanced the degree of microphase separation and the mechanical strength of all the polymers. The more polar PEO soft segment resulted in polymers which were more phase mixed than the PTMO-based polyurethanes. Surface characterization studies revealed that in vacuum, all the surfaces were enriched in the polyether soft-segment phase. After 24-h equilibration in water, all the surfaces had similar surface polarities independent of the SO3H content. The canine ex vivo blood-contacting results showed that the sulfonic acid group in the PTMO-based polymers significantly reduced the number and activation of the adherent platelets. Fibrinogen deposition, however, increased with increasing sulfonic acid content. In contrast, platelet and fibrinogen deposition on the sulfonic acid-containing PEO-based polymers was greatly enhanced.     

Effect of surface hydrophilicity on ex vivo blood compatibility of segmented polyurethanes

The relationship between surface, bulk and ex vivo blood-contacting properties of segmented polyurethanes with various polyol soft segment was investigated. The polyols used in this study were poly(ethylene oxide), poly(tetramethylene oxide), hydrogenated poly(butadiene), poly(butadiene) and poly(dimethylsiloxane). The hard segment of these segmented polyurethanes was composed of 4,4' diphenylmethane diisocyanate and 1,4 butanediol, present at 50 wt%. An experimental polyurethane, Biostable PUR, which has shown excellent biostability, was used in this study. The segmented polyurethanes based on the hydrophobic polyols such as poly(dimethylsiloxane) and hydrogenated poly(butadiene) showed distinct microphase separation between hard and soft segments. X-ray photoelectron spectroscopy revealed the surface enrichment of the hydrophobic component at the air-solid interface. Dynamic contact angle measurements indicated that the poly(dimethylsiloxane)-based segmented polyurethane possessed a hydrophobic surface in water. The poly(dimethylsiloxane)-based segmented polyurethane had the lowest platelet adhesion among the segmented polyurethanes investigated in this study, whilst the platelet deposition on the poly(ethylene oxide)-based polymer increased with time.     

Poly(carbonate urethane) and poly(ether urethane) biodegradation: in vivo studies

Several strategies have been used to increase the biostability of medical-grade polyurethanes while maintaining biocompatibility and mechanical properties. One approach is to chemically modify or replace the susceptible soft segment. Currently, poly(carbonate urethanes) (PCUs) are being evaluated as a replacement of poly(ether urethanes) (PEUs) in medical devices because of the increased oxidative stability of the polycarbonate soft segment. Preliminary in vivo and in vitro studies have reported improved biostability of PCUs over PEUs. Although several studies have reported evidence of in vitro degradation of these new polyurethanes, there has been no evidence of significant in vivo degradation that validates a degradation mechanism. In this study, the effect of soft segment chemistry on the phase morphology, mechanical properties, and in vivo response of commercial-grade PEU and PCU elastomers was examined. Results from dynamic mechanical testing and infrared spectroscopy suggested that the phase separation was better in PCU as compared with PEU. In addition, the higher modulus and reduced ultimate elongation of PCU was attributed to the reduced flexibility of the polycarbonate soft segment. Following material characterization, the in vivo biostability and biocompatibility of PEU and PCU were studied using a subcutaneous cage implant protocol. The results from the cage implant study and cell culture experiments indicated that monocytes adhere, differentiate, and fuse to form foreign body giant cells on both polyurethanes. It is now generally accepted that the reactive oxygen species released by these adherent macrophages and foreign body giant cells initiate PEU biodegradation. Attenuated total reflectance-Fourier transform infrared analysis of explanted samples provided evidence of chain scission and crosslinking in both polyurethanes. This indicated that the PCU was also susceptible to biodegradation by agents released from adherent cells. These results reinforce the need to evaluate and understand the biodegradation mechanisms of PCUs.     

Heparin immobilization onto segmented polyurethane-urea surfaces--effect of hydrophilic spacers

Heparin was immobilized onto segmented polyurethane-urea surfaces (Biomer) using hydrophilic poly(ethylene oxide) spacers of different chain lengths. The use of the hydrophilic spacer, poly(ethylene oxide), reduces protein adsorption and subsequent platelet adhesion on the surface. In addition, the bioactivity of the immobilized heparin is enhanced by the incorporation of these spacers. Immobilized heparin bioactivity is shown to be a function of PEO spacer length. Use of hydrophilic PEO spacers demonstrates that immobilized heparin's bioactivity is consistently higher than that of the C6 alkyl spacer, but heparin-immobilized surfaces demonstrate no chain length effect on platelet adhesion, even though they show less platelet adhesion compared to Biomer controls. In the case of PEO-grafted surfaces, platelet adhesion is decreased compared to Biomer controls, and C6 alkyl spacer-grafted surfaces, and exhibits a minimum at PEO 1000. In ex vivo A-A shunt experiments under low flow and low shear conditions, all heparinized surfaces exhibit significant prolongation of occlusion times compared to Biomer controls, indicating an ability of immobilized heparin to inhibit thrombosis in whole blood.     

Properties of extruded poly(tetramethylene oxide)-polyurethane block copolymers for blood-contacting applications

The bulk and surface properties and blood compatibility of a series of polyurethanes based on methylene bis(p-phenyl isocyanate), 1,4-butanediol, and poly(tetramethylene oxide) of molecular weight 1000 were studied. The hard-to-soft segment ratio of these multiphase polymers was varied, and the effect of substituting a poly(dimethylsiloxane)-containing polyol in place of 5% of the polyether soft segment was studied. Bulk properties such as tensile strength and modulus increased with hard segment content, as did surface wettability and ESCA nitrogen content. However, blood compatibility measured by a canine ex vivo blood-contacting experiment was not found to vary with hard/soft segment ratio. The addition of the silicone-containing polyol did not significantly lower the surface wettability, although ESCA-measured silicon content increased and physical properties were unfavourably affected by the incorporation of this co-soft segment. Incorporation of the siloxane-containing component resulted in increased platelet adhesion and fibrinogen deposition at most blood contact times in comparison with the other polyurethanes.     

Blood compatibility of SPUU-PEO-heparin graft copolymers.

Biological responses to heparinized segmented polyurethaneurea (SPUU-PEO-Heparin) were evaluated in vitro and ex vivo. In vitro assays involved plasma protein adsorption, platelet adhesion, and release reaction studies. In addition, an ex vivo rabbit arterio-artery (A-A) shunt experiment was also performed to measure occlusion times of the heparinized surfaces. All SPUU-PEO-Heparin surfaces demonstrated less protein adsorption than Biomer and protein adsorption patterns similar to SPUU-PEO surfaces. Platelet adhesion and release studies demonstrated that both SPUU-PEO-Heparin and SPUU-PEO surfaces adsorbed less platelets and inhibited platelet release, as compared to Biomer. These findings correlated with reduction in protein adsorption observed for the modified surfaces. In low flow rate ex-vivo A-A shunt experiments, all heparinized surfaces prolonged occlusion time longer than controls. However, SPUU-PEO surfaces did not prolong occlusion time when compared to Biomer, although these surfaces suppressed protein adsorption and platelet interaction in vitro. The improved blood compatibility of SPUU-PEO-Heparin surfaces attest to the usefulness of this approach in improving the blood compatibility of blood contacting surfaces.     

Effect of carboxylate and/or sulphonate ion incorporation on the physical and blood-contacting properties of a polyetherurethane.

Propyl sulphonate and ethyl carboxylate groups were grafted on to the backbone of a polytetramethylene oxide-based polyurethane (PEU). The effects of ion type and ion content on the polymer's bulk, surface, and blood-contacting properties were evaluated. Ion incorporation disrupted the packing of the hard segment but had little effect on the overall microphase separation of the polymers. The mechanical properties of the ionomers were improved relative to the base PEU, although the carboxylate-containing ionomers were weaker than the sulphonate-containing polymers. As expected, the polymer's water absorption and surface polarity increased with increasing ion content. Dynamic and static contact angle analysis indicated that the propyl sulphonate-containing polymers were more polar than the ethyl carboxylate-containing polymers at the same ion content which is attributed to the higher ionic strength of the sulphonate ion. The carboxylate-containing polymers had no statistically significant effect on the polymer's canine ex vivo blood-contacting response. At the same ion content, propyl sulphonate incorporation significantly reduced platelet deposition for very short blood-contacting times. When both ion types were present in the polymer, the propyl sulphonate group appeared to be the primary factor determining the polymer's blood-contacting response. The polymer containing 20 mol% propyl sulphonate groups significantly reduced platelet deposition and activation while also exhibiting enhanced fibrinogen deposition.     

Surface properties and blood compatibility of polyurethaneureas

A series of polyurethaneureas of varying soft segment type and hard/soft segment ratio were synthesized, and their bulk and surface properties evaluated. A canine ex vivo arteriovenous series shunt was used to monitor initial thrombus deposition. Significant levels of surface hard segment components are apparent in these materials. Polymers with poly(tetramethylene oxide) and poly(propylene oxide) soft segments showed blood compatibility variations with changes in hard/soft segment ratios: the more well-phase-separated materials showing lower platelet and fibrinogen deposition levels. Those trends apparent in polymers synthesized with poly(dimethylsiloxane) or poly(ethylene oxide) soft segments, but poly(dimethylsiloxane)-based materials showed higher levels of thrombus deposition than the poly(ethylene oxide)-based polymers.     

Transient in vivo protein adsorption onto polymeric biomaterials.

The adsorption of albumin, gamma-globulin, and fibrinogen was measured on three ex vivo polymeric shunt surfaces [polyvinyl chloride (PVC), Silastic, and segmented polyether urethane (Biomer)] exposed to flowing heparinized, canine blood in vivo. Small amounts of radiolabeled proteins were infused into anesthetized mongrel dogs and the deposition of radioactivity on the walls of femoral arteriovenous shunts was followed with time for two hours following initial blood-polymer contact. Previously, transient in vivo platelet and fibrin deposition onto PVC, Silastic, and Biomer was measured by a similar technique in the absence of anticoagulant. A time-dependent phase of thrombus deposition followed by thromboembolism was observed on the PVC and Silastic shunt surfaces but not on the Biomer surface. In the studies reported here on PVC and Silastic, fibrinogen adsorption was found to predominate initially, though it subsequently desorbed somewhat and was replaced by albumin and gamma-globulin. On Biomer, the adsorption of all three proteins increased with time following initial blood contact and fibrinogen was less prominent initially. The PVC surface was found to become passivated with respect to further thrombogenesis after 60-min exposure to flowing blood, at which time a higher fraction of albumin was present on the surface compared to that at earlier blood contact times. These results indicate that rearrangement of adsorbed protein species occurs with time on polymer surfaces exposed to flowing blood in vivo. Early and predominant fibrinogen adsorption appears to be an important factor in the thrombogenic and embolic events observed on the PVC and Silastic shunt surfaces in vivo.     

Effects of alkyl grafting on surface properties and blood compatibility of polyurethane block copolymers

In order to probe the factors which affect the interaction between the surface of a multiphase polyurethane material and blood, a series of butanediol-chain-extended polyetherurethanes was synthesized. These polyurethanes contained different levels of phase separation, produced by systematically varying the hard segment chemical structure by grafting ethyl and octadecyl groups to the urethane nitrogen atom. Surface characterization using high vacuum, air-equilibrated, and water-equilibrated methods was performed. A canine ex vivo arteriovenous series shunt was used to monitor initial platelet and fibrinogen deposition on these polymers. The ex vivo response to these materials, along with contact angle and ESCA surface chemistry, was found to vary with the degree of alkyl derivatization. This study demonstrated that an increase in the degree of phase separation and also the incorporation of long chain (C18) alkyl groups can affect surface properties and improve the short-term blood compatibility of the underivatized polyurethane.     

Biostability and macrophage-mediated foreign body reaction of silicone-modified polyurethanes

In this study, the effect of soft segment chemistry on the phase morphology and in vivo response of commercial-grade poly(ether urethane) (PEU), silicone-modified PEU (PEU-S), poly(carbonate urethane) (PCU), and silicone-modified PCU (PCU-S) elastomers were examined. Silicone-modified polyurethanes were developed to combine the biostability of silicone with the mechanical properties of PEUs. Results from the infrared spectroscopy confirmed the presence of silicone at the surface of the PEU-S and PCU-S films. Atomic force microscopy phase imaging indicated that the overall two-phase morphology of PEUs, necessary for its thermoplastic elastomeric properties, was not disrupted by the silicone modification. After material characterization, the in vivo foreign body response and biostability of the polyurethanes were studied using a subcutaneous cage implant protocol. The results from the cage implant study indicated that monocytes adhere, differentiate to macrophages which fuse to form foreign body giant cells on all of the polyurethanes. However, the silicone-modified surfaces promoted apoptosis of adherent macrophages at 4 days and high levels of macrophage fusion after 21 days. These results confirm that the surface of a biomaterial may influence the induction of apoptosis of adherent macrophages in vivo and are consistent with previous cell culture studies of these materials. This study validates the use of our standard cell culture protocol to predict in vivo behavior and further supports the hypothesis that interleukin-4 is the primary mediator of macrophage fusion and foreign body giant cell formation in vivo. The impact of these findings on the biostability of polyurethanes is the subject of current investigations. Attenuated total reflectance-Fourier transform infrared analysis of explanted specimens provided evidence of chain scission and crosslinking at the surface of all of the polyurethanes. The silicone modification did not fully inhibit the oxidative biodegradation of the polyether or polycarbonate soft segments; however, the rate of chain scission of PEU-S and PCU-S seemed to be slower than the control polyurethanes. To verify this finding and to quantify the rate of chain scission in order to predict long-term biostability, an in vitro environment that simulated the microenvironment at the adherent cell-material interface was used to accelerate the biodegradation of the polyurethanes. Polyurethane films were treated in vitro for up to 36 days in 20% hydrogen peroxide/0.1M cobalt chloride solution at 37 degrees Celsius. Characterization with attenuated total reflectance-Fourier transform infrared and scanning electron microscopy showed soft segment and hard segment degradation consistent with the chemical changes observed after long-term in vivo treatment. The biostability ranking of these four materials based on rate of chain scission and surface pitting was as follows: PEU < PEU-S PCU < PCU-S. The silicone modification increased the biostability of the PEU and PCU elastomers while maintaining the thermoplastic elastomeric properties.     

含氟聚醚聚氨酯与聚醚聚氨酯共混的表面结构及血液相容性的研究

为了获得一种高氟聚氨酯表面 ,进一步改善聚醚聚氨酯的生物相容性和生物稳定性 ,将侧链含氟聚氨酯与聚醚聚氨酯共混而实现这一目的。通过 XPS、AFM、接触角和血小板黏附对含氟聚醚聚氨酯和聚醚聚氨酯共混物表面结构和血液相容性进行研究发现 ,在聚醚聚氨酯共混入极少量的氟 (0 .342 wt% )就能具有与含氟聚醚聚氨酯相同的表面结构和良好的血液相容性 ,而且共混物表面的强疏水性和对血小板的黏附与体系中混入的含氟聚醚聚氨酯的量无关 ,与表面 CF3的含量有关     

Long-term in vivo biostability of poly(dimethylsiloxane)/poly(hexamethylene oxide) mixed macrodiol-based polyurethane elastomers

The long-term biostability of a novel thermoplastic polyurethane elastomer (Elast-Eon 2 80A) synthesized using poly(hexamethylene oxide) (PHMO) and poly(dimethylsiloxane) (PDMS) macrodiols has been studied using an in vivo ovine model. The material's biostability was compared with that of three commercially available control materials, Pellethane 2363-80A, Pellethane 2363-55D and Bionate 55D, after subcutaneous implantation of strained compression moulded flat sheet dumbbells in sheep for periods ranging from 3 to 24 months. Scanning electron microscopy, attenuated total reflectance-Fourier transform infrared spectroscopy, and X-ray photoelectron spectroscopy were used to assess changes in the surface chemical structure and morphology of the materials. Gel permeation chromatography, differential scanning calorimetry and tensile testing were used to examine changes in bulk characteristics of the materials. The results showed that the biostability of the soft flexible PDMS-based test polyurethane was significantly better than the control material of similar softness, Pellethane 80A, and as good as or better than both of the harder commercially available negative control polyurethanes, Pellethane 55D and Bionate 55D. Changes observed in the surface of the Pellethane materials were consistent with oxidation of the aliphatic polyether soft segment and hydrolysis of the urethane bonds joining hard to soft segment with degradation in Pellethane 80A significantly more severe than that observed in Pellethane 55D. Very minor changes were seen on the surfaces of the Elast-Eon 2 80A and Bionate 55D materials. There was a general trend of molecular weight decreasing with time across all polymers and the molecular weights of all materials decreased at a similar relative rate. The polydispersity ratio, Mw/Mn, increased with time for all materials. Tensile tests indicated that UTS increased in Elast-Eon 2 80A and Bionate 55D following implantation under strained conditions. However, ultimate strain decreased and elastic modulus increased in the explanted specimens of all three materials when compared with their unimplanted unstrained counterparts. The results indicate that a soft, flexible PDMS-based polyurethane synthesized using 20% PHMO and 80% PDMS macrodiols has excellent long-term biostability compared with commercially available polyurethanes.     

Ex vivo and in vitro platelet adhesion on RFGD deposited polymers.

Clinical applications of small-diameter synthetic vascular grafts are hindered by their highly thrombogenic surfaces. To develop vascular grafts that resist thrombotic occlusion, a radio frequency glow discharge (RFGD) process was employed to modify the surface of existing graft materials. Ultrathin coatings of RFGD polymers of ethylene (E), tetrafluoroethylene (TFE), and hexamethyldisiloxane (HMDS) were deposited on the lumen of Dacron grafts. Surfaces were characterized by electron spectroscopy for chemical analysis (ESCA). The effect of glow discharge treatments on platelet-graft interactions was evaluated in an ex vivo baboon shunt model. Following placement of an untreated or RFGD-treated graft in the shunt, deposition of 111Indium-labeled platelets was monitored for 60 min by gamma camera imaging. Untreated Dacron rapidly accumulated large numbers of platelets, reaching a plateau in 60 min. HMDS- and TFE-treated Dacron had significantly lower levels of platelet deposition compared to the untreated control. In contrast, the ethylene treatment of Dacron augmented platelet deposition, making it the most platelet-adherent surface studied. In vitro studies were also performed using untreated and RFGD-treated poly (ethylene terephthalate) (PET) coverslips. ESCA verified that the surface composition of the untreated and RFGD-treated coverslips were virtually identical to their untreated and treated Dacron graft counterparts. Samples were incubated in washed baboon platelet suspensions for 2 h at 37 degrees C. Platelet adhesion on the untreated PET was relatively high, and many of the platelets had a completely spread morphology. The HMDS and TFE treatment of PET reduced the number of adherent platelets and prevented platelet spreading on the surface. Platelet adhesion and spreading on the ethylene-treated surface was the highest among the four studied. There is a remarkable linear correlation of the ex vivo and in vitro platelet adhesion data.