Are Fe-Based Stenting Materials Biocompatible? A Critical Review of In Vitro and In Vivo Studies

Fe-based materials have increasingly been considered for the development of biodegradable cardiovascular stents. A wide range of in vitro and in vivo studies should be done to fully evaluate their biocompatibility. In this review, we summarized and analyzed the findings and the methodologies used to assess the biocompatibility of Fe materials. The majority of investigators drew conclusions about in vitro Fe toxicity based on indirect contact results. The setup applied in these tests seems to overlook the possible effects of Fe corrosion and does not allow for understanding of the complexity of released chemical forms and their possible impact on tissue. It is in particular important to ensure that test setups or interpretations of in vitro results do not hide some important mechanisms, leading to inappropriate subsequent in vivo experiments. On the other hand, the sample size of existing in vivo implantations is often limited, and effects such as local toxicity or endothelial function are not deeply scrutinized. The main advantages and limitations of in vitro design strategies applied in the development of Fe-based alloys and the correlation with in vivo studies are discussed. It is evident from this literature review that we are not yet ready to define an Fe-based material as safe or biocompatible.