Anatomical flow phantoms of the nonplanar carotid bifurcation, part II: experimental validation with Doppler ultrasound

Fabrication of deformable patient-specific AAA models by material casting techniques

Background

Abdominal Aortic Aneurysm (AAA) is a balloon-like dilatation that can be life-threatening if not treated. Fabricating patient-specific AAA models can be beneficial for in-vitro investigations of hemodynamics, as well as for pre-surgical planning and training, testing the effectiveness of different interventions, or developing new surgical procedures. The current direct additive manufacturing techniques cannot simultaneously ensure the flexibility and transparency of models required by some applications. Therefore, casting techniques are presented to overcome these limitations and make the manufactured models suitable for in-vitro hemodynamic investigations, such as particle image velocimetry (PIV) measurements or medical imaging.

Methods

Two complex patient-specific AAA geometries were considered, and the related 3D models were fabricated through material casting. In particular, two casting approaches, i.e. lost molds and lost core casting, were investigated and tested to manufacture the deformable AAA models. The manufactured models were acquired by magnetic resonance, computed tomography (CT), ultrasound imaging, and PIV. In particular, CT scans were segmented to generate a volumetric reconstruction for each manufactured model that was compared to a reference model to assess the accuracy of the manufacturing process.

Results

Both lost molds and lost core casting techniques were successful in the manufacturing of the models. The lost molds casting allowed a high-level surface finish in the final 3D model. In this first case, the average signed distance between the manufactured model and the reference was (- 0.2 ± 0.2 ) mm. However, this approach was more expensive and time-consuming. On the other hand, the lost core casting was more affordable and allowed the reuse of the external molds to fabricate multiple copies of the same AAA model. In this second case, the average signed distance between the manufactured model and the reference was (0.1 ± 0.6 ) mm. However, the final model's surface finish quality was poorer compared to the model obtained by lost molds casting as the sealing of the outer molds was not as firm as the other casting technique.

Conclusions

Both lost molds and lost core casting techniques can be used for manufacturing patient-specific deformable AAA models suitable for hemodynamic investigations, including medical imaging and PIV.

Development of Ultrasound Phantom Made of Transparent Material: Feasibility of Optical Particle Image Velocimetry

OBJECTIVE

The need for ultrasound flow phantoms to validate ultrasound systems requires the development of materials that can clearly visualize the flow inside for measurement purposes.

METHODS

A transparent ultrasound flow phantom material composed of poly(vinyl alcohol) hydrogel (PVA-H) with dimethyl sulfoxide (DMSO) and water solution manufactured using the freezing method and mixed with quartz glass powder to exhibit scattering effects is proposed. To achieve transparency of the hydrogel phantom, the refractive index (RI) was changed to match that of the glass by modifying the PVA concentration and the ratio of DMSO to water in the solvent. The feasibility of optical particle image velocimetry (PIV) was verified by comparing an acrylic rectangular cross-section channel with a rigid wall. After the feasibility tests, an ultrasound flow phantom was fabricated to conduct ultrasound B-mode visualization and Doppler-PIV comparison.

DISCUSSION

The results revealed that the PIV measured through PVA-H material exhibited 0.8% error in the measured maximum velocity compared with PIV through the acrylic material. B-mode images are similar to real tissue visualization with a limitation of a higher sound velocity, when compared with human tissue, of 1792 m/s. Doppler measurement of the phantom revealed approximately 120% and 19% overestimation of maximum and mean velocities, respectively, compared with those from PIV.

CONCLUSION

The proposed material possesses the advantage of the single-phantom ability to improve the ultrasound flow phantom for validation of flow.

Use of 3D anatomical models in mock circulatory loops for cardiac medical device testing

INTRODUCTION

Mock circulatory loops (MCLs) are mechanical representations of the cardiovascular system largely used to test the hemodynamic performance of cardiovascular medical devices (MD). Thanks to 3 dimensional (3D) printing technologies, MCLs can nowadays also incorporate anatomical models so to offer enhanced testing capabilities. The aim of this review is to provide an overview on MCLs and to discuss the recent developments of 3D anatomical models for cardiovascular MD testing.

METHODS

The review first analyses the different techniques to develop 3D anatomical models, in both rigid and compliant materials. In the second section, the state of the art of MCLs with 3D models is discussed, along with the testing of different MDs: implantable blood pumps, heart valves, and imaging techniques. For each class of MD, the MCL is analyzed in terms of: the cardiovascular model embedded, the 3D model implemented (the anatomy represented, the material used, and the activation method), and the testing applications.

DISCUSSIONS AND CONCLUSIONS

MCLs serve the purpose of testing cardiovascular MDs in different (patho-)physiological scenarios. The addition of 3D anatomical models enables more realistic connections of the MD with the implantation site and enhances the testing capabilities of the MCL. Current attempts focus on the development of personalized MCLs to test MDs in patient-specific hemodynamic and anatomical scenarios. The main limitation of MCLs is the impossibility to assess the impact of a MD in the long-term and at a biological level, for which animal experiments are still needed.

Acoustic characterization of tissue-mimicking materials for ultrasound perfusion imaging research

Materials with well-characterized acoustic properties are of great interest for the development of tissue-mimicking phantoms with designed (micro)vasculature networks. These represent a useful means for controlled in-vitro experiments to validate perfusion imaging methods such as Doppler and contrast-enhanced ultrasound (CEUS) imaging. In this work, acoustic properties of seven tissue-mimicking phantom materials at different concentrations of their compounds and five phantom case materials are characterized and compared at room temperature. The goal of this research is to determine the most suitable phantom and case material for ultrasound perfusion imaging experiments. The measurements show a wide range in speed of sound varying from 1057 to 1616 m/s, acoustic impedance varying from 1.09 to 1.71 × 10⁶ kg/m²s, and attenuation coefficients varying from 0.1 to 22.18 dB/cm at frequencies varying from 1 MHz to 6 MHz for different phantom materials. The nonlinearity parameter B/A varies from 6.1 to 12.3 for most phantom materials. This work also reports the speed of sound, acoustic impedance and attenuation coefficient for case materials. According to our results, polyacrylamide (PAA) and polymethylpentene (TPX) are the optimal materials for phantoms and their cases, respectively. To demonstrate the performance of the optimal materials, we performed power Doppler ultrasound imaging of a perfusable phantom, and CEUS imaging of that phantom and a perfusion system. The obtained results can assist researchers in the selection of the most suited materials for in-vitro studies with ultrasound imaging.

Glycerol-in-SEBS gel as a material to manufacture stable wall-less vascular phantom for ultrasound and photoacoustic imaging

Styrene-ethylene/butylene-styrene (SEBS) copolymer-in-mineral oil gel is an appropriate tissue-mimicking material to manufacture stable phantoms for ultrasound and photoacoustic imaging. Glycerol dispersion has been proposed to further tune the acoustic properties and to incorporate hydrophilic additives into SEBS gel. However, this type of material has not been investigated to produce wall-less vascular flow phantom for these imaging modalities. In this paper, the development of a wall-less vascular phantom for ultrasound and photoacoustic imaging is reported. Mixtures of glycerol/TiO₂-in-SEBS gel samples were manufactured at different proportions of glycerol (10%, 15%, and 20%) and TiO₂(0% to 0.5%) to characterize their optical and acoustic properties. Optical absorption in the 500-950 nm range was independent of the amount of glycerol and TiO₂, while optical scattering increased linearly with the concentration of TiO₂. Acoustic attenuation and speed of sound were not influenced by the presence of TiO₂. The sample manufactured using weight percentages of 10% SEBS, 15% glycerol, and 0.2% TiO₂was selected to make the vascular phantom. The phantom proved to be stable during the pulsatile blood-mimicking fluid (BMF) flow, without any observed damage to its structure or leaks. Ultrasound color Doppler images showed a typical laminar flow, while the B-mode images showed a homogeneous speckled pattern due to the presence of the glycerol droplets in the gel. The photoacoustic images of the phantom showed a well-defined signal coming from the surface of the phantom and from the vessels where BMF was flowing. The Spearman's correlations between the photoacoustic and tabulated spectra calculated from the regions containing BMF, in this case a mixture of salt solutions (NiCl₂and CuSO₄), were higher than 0.95. Our results demonstrated that glycerol-in-SEBS gel was an adequate material to make a stable vascular flow phantom for ultrasound photoacoustic imaging.

Compatibility and Validation of a Recent Developed Artificial Blood through the Vascular Phantom Using Doppler Ultrasound Color- and Motion-mode Techniques

Background:

Doppler technique is a technology that can raise the predictive, diagnostic, and monitoring abilities in blood flow and suitable for researchers. The application depends on Doppler shift (shift frequencies), wherein the movement of red blood cells away from the probe is determined by the decrease or increase in the ultrasound (US) frequency.

Methods:

In this experiment, the clinical US (Hitachi Avious [HI] model) system was used as a primary instrument for data acquisition and test the compatibility, efficacy, and validation of artificial blood (blood-mimicking fluid [BMF]) by color- and motion-mode. This BMF was prepared for use in the Doppler flow phantom.

Results:

The motion of BMF through the vessel-mimicking material (VMM) was parallel and the flow was laminar and in the straight form (regular flow of BMF inside the VMM). Moreover, the scale of color velocity in the normal range at that flow rate was in the normal range.

Conclusion:

The new BMF that is being valid and effective in utilizing for US in vitro research applications. In addition, the clinical US ([HI] model) system can be used as a suitable instrument for data acquisition and test the compatibility, efficacy, and validation at in vitro applications (BMF, flow phantom components).

Helical toroid phantom for 3D flow imaging investigations

The medical physics community has hitherto lacked an effective calibration phantom to holistically evaluate the performance of three-dimensional (3D) flow imaging techniques. Here, we present the design of a new omnidirectional, three-component (3-C) flow phantom whose lumen is consisted of a helical toroid structure (4 mm lumen diameter; helically winded for 5 revolutions over a torus with 10 mm radius; 5 mm helix radius). This phantom's intraluminal flow trajectory embraces all combinations of x, y, and z directional components, as confirmed using computational fluid dynamics (CFD) simulations. The phantom was physically fabricated via lost-core casting with polyvinyl alcohol cryogel (PVA) as the tissue mimic. 3D ultrasound confirmed that the phantom lumen expectedly resembled a helical toroid geometry. Pulsed Doppler measurements showed that the phantom, when operating under steady flow conditions (3 ml s^-1 flow rate), yielded flow velocity magnitudes that agreed well with those derived from CFD at both the inner torus (-47.6 ± 5.7 versus -52.0 ± 2.2 cm s^-1; mean ± 1 S.D.) and the outer torus (49.5 ± 4.2 versus 48.0 ± 1.7 cm s^-1). Additionally, 3-C velocity vectors acquired from multi-angle pulsed Doppler showed good agreement with CFD-derived velocity vectors (<7% and 10° difference in magnitude and flow angle, respectively). Ultrasound color flow imaging further revealed that the phantom's axial flow pattern was aligned with the CFD-derived flow profile. Overall, the helical toroid phantom has strong potential as an investigative tool in 3D flow imaging innovation endeavors, such as the development of flow vector estimators and visualization algorithms.

Application of the novel estimation method by shear wave elastography using vibrator to human skeletal muscle

In recent years, non-invasive measurement of tissue stiffness (hardness) using ultrasound elastography has attracted considerable attention. It has been used to evaluate muscle stiffness in the fields of rehabilitation, sports, and orthopedics. However, ultrasonic diagnostic devices with elastography systems are expensive and clinical use of such devices has been limited. In this study, we proposed a novel estimation method for vibration-based shear wave elastography measurement of human skeletal muscle, then determined its reproducibility and reliability. The coefficient of variation and correlation coefficient were used to determine reproducibility and reliability of the method by measuring the shear wave velocities in konjac phantom gels and agar phantom gels, as well as skeletal muscle. The intra-day, day-to-day, and inter-operator reliabilities were good when measuring the shear wave velocities in phantom gels. The intra-day and day-to-day reliabilities were good when measuring the shear wave velocities in skeletal muscle. The findings confirmed adequate reproducibility and reliability of the novel estimation method for vibration-based shear wave elastography. Therefore, the proposed measurement method may be a useful tool for evaluation of muscle stiffness.

A Brief Review for Common Doppler Ultrasound Flow Phantoms

In this review, the flow phantoms and the wall-less flow phantoms with recognized acoustic features (attenuation and speed of sound), interior properties, and dimensions of tissue were prepared, calibrated, and characterized by Doppler ultrasound (US) scanning which demands tissue-mimicking materials (TMMs). TMM phantoms are commercially available and readymade for medical US applications. Furthermore, the commercial TMM phantoms are proper for US purpose or estimation of diagnostic imaging techniques according to the chemical materials used for its preparation.

Investigation of the assessment of low degree (<50%) renal artery stenosis based on velocity flow profile analysis using Doppler ultrasound: An in-vitro study

PURPOSE

Renal arterial stenosis can lead to disrupted renal function due to reduced blood flow to the kidneys and is largely thought to be caused by atherosclerosis. Current diagnostic strategies for renal arterial stenosis rely on detecting large degree stenoses (>50%). This study aimed to test the viability of using Doppler ultrasound to assess velocity profiles to detect the presence of low degree (<50%) stenoses.

METHODS

A series of anatomically realistic renal artery flow phantoms were constructed exhibiting a range of low degree stenoses (symmetric and asymmetric). The behaviour of fluid flow in the phantoms was examined using Doppler ultrasound and analysed to calculate the clinical biomarker, wall shear stress.

RESULTS

A number of fluid behaviours were observed in relation to stenosis degree: asymmetric stenoses tended to result in a skewing of peak velocities away from the centre of the vessel towards the outer wall, the magnitude of increase in velocity was observed to correlate with stenosis degree, and the wall shear stress curves observed large peaks in the presence of even the lowest degree stenosis (20%).

CONCLUSIONS

Doppler ultrasound could potentially be utilised to diagnose low degree stenoses in a clinical setting. Doppler ultrasound in conjunction with wall shear stress analysis in particular has significant potential in the diagnosis of renal artery stenosis.

Chemical Items Used for Preparing Tissue-Mimicking Material of Wall-Less Flow Phantom for Doppler Ultrasound Imaging

The wall-less flow phantoms with recognized acoustic features (attenuation and speed of sound), interior properties, and dimensions of tissue were prepared, calibrated, and characterized of Doppler ultrasound scanning demands tissue-mimicking materials (TMMs). TMM phantoms are commercially available and ready-made for medical ultrasound applications. Furthermore, the commercial TMM phantoms are proper for ultrasound purpose or estimation of diagnostic imaging techniques according to the chemical materials used for its preparation. However, preparing a desirable TMM for wall-less flow phantom using a specific chemical material according to the specific applications is required for different flow. In this review, TMM and wall-less flow phantoms prepared using different chemical materials and methods were described. The chemical materials used in Doppler ultrasound TMM and wall-less flow phantoms fabricated over the previous decades were of high interest in this review.

Broadband Acoustic Measurement of an Agar-Based Tissue-Mimicking-Material: A Longitudinal Study

Commercially available ultrasound quality assurance test phantoms rely on the long-term acoustic stability of the tissue-mimicking-material (TMM). Measurement of the acoustic properties of the TMM can be technically challenging, and it is important to ensure its stability. The standard technique is to film-wrap samples of TMM and to measure the acoustic properties in a water bath. In this study, a modified technique was proposed whereby the samples of TMM are measured in a preserving fluid that is intended to maintain their characteristics. The acoustic properties were evaluated using a broadband pulse-echo substitution technique over the frequency range 4.5-50 MHz at 0, 6 and 12 months using both techniques. For both techniques, the measured mean values for the speed of sound and attenuation were very similar and within the International Electrotechnical Commission-recommended value. However, the results obtained using the proposed modified technique exhibited greater stability over the 1-y period compared with the results acquired using the standard technique.

Fabrication of Two Flow Phantoms for Doppler Ultrasound Imaging

Flow phantoms are widely used in studies associated with Doppler ultrasound measurements, acting as an effective experimental validation system in cardiovascular-related research and in new algorithm/instrumentation development. The development of materials that match the acoustic and mechanical properties of the vascular system is of great interest while designing flow phantoms. Although recipes that meet the flow phantom standard defined by the International Electrotechnical Commission 61685 are already available in the literature, the standard procedure for material preparations and phantom fabrications has not been well established. In this paper, two types of flow phantoms, with and without blood vessel mimic, are described in detail in terms of the material preparation and phantom fabrication. The phantom materials chosen for the two phantoms are from published phantom studies, and their physical properties have been investigated previously. Both the flow phantoms have been scanned by ultrasound scanners and images from different modes are presented. These phantoms may be used in the validation and characterization of Doppler ultrasound measurements in blood vessels with a diameter above 1 mm.

Wall-Less Flow Phantoms With Tortuous Vascular Geometries: Design Principles and a Patient-Specific Model Fabrication Example

Flow phantoms with anatomically realistic geometry and high acoustic compatibility are valuable investigative tools in vascular ultrasound studies. Here, we present a new framework to fabricate ultrasound-compatible flow phantoms to replicate human vasculature that is tortuous, nonplanar, and branching in nature. This framework is based upon the integration of rapid prototyping and investment casting principles. A pedagogical walkthrough of our engineering protocol is presented in this paper using a patient-specific cerebral aneurysm model as an exemplar demonstration. The procedure for constructing the flow circuit component of the phantoms is also presented, including the design of a programmable flow pump system, the fabrication of blood mimicking fluid, and flow rate calibration. Using polyvinyl alcohol cryogel as the tissue mimicking material, phantoms developed with the presented protocol exhibited physiologically relevant acoustic properties [attenuation coefficient: 0.229±0.032 dB/( [Formula: see text]) and acoustic speed: 1535±2.4 m/s], and their pulsatile flow dynamics closely resembled the flow profile input. As a first application of our developed phantoms, the flow pattern of the patient-specific aneurysm model was visualized by performing high-frame-rate color-encoded speckle imaging over multiple time-synchronized scan planes. Persistent recirculation was observed, and the vortex center was found to shift in position over a cardiac cycle, indicating the 3-D nature of flow recirculation inside an aneurysm. These findings suggest that phantoms produced from our reported protocol can serve well as acoustically compatible test beds for vascular ultrasound studies, including 3-D flow imaging.

Walled Carotid Bifurcation Phantoms for Imaging Investigations of Vessel Wall Motion and Blood Flow Dynamics

As a major application domain of vascular ultrasound, the carotid artery has long been the subject of anthropomorphic phantom design. It is nevertheless not trivial to develop walled carotid phantoms that are compatible for use in integrative imaging of carotid wall motion and flow dynamics. In this paper, we present a novel phantom design protocol that can enable efficient fabrication of walled carotid bifurcation phantoms with: (i) high acoustic compatibility, (ii) artery-like vessel elasticity, and (iii) stenotic narrowing feature. Our protocol first involved direct fabrication of the vessel core and an outer mold using computer-aided design tools and 3-D printing technology; these built parts were then used to construct an elastic vessel tube through investment casting of a polyvinyl alcohol containing mixture, and an agar-gelatin tissue mimicking slab was formed around the vessel tube. For demonstration, we applied our protocol to develop a set of healthy and stenosed (25%, 50%, 75%) carotid bifurcation phantoms. Plane wave imaging experiments were performed on these phantoms using an ultrasound scanner with channel-level configurability. Results show that the wall motion dynamics of our phantoms agreed with pulse wave propagation in an elastic vessel (pulse wave velocity of 4.67±0.71 m/s measured at the common carotid artery), and their flow dynamics matched the expected ones in healthy and stenosed bifurcation (recirculation and flow jet formation observed). Integrative imaging of vessel wall motion and blood flow dynamics in our phantoms was also demonstrated, from which we observed fluid-structure interaction differences between healthy and diseased bifurcation phantoms. These findings show that the walled bifurcation phantoms developed with our new protocol are useful in vascular imaging studies that individually or jointly assess wall motion and flow dynamics.

Construction of 3-Dimensional Printed Ultrasound Phantoms With Wall-less Vessels

Ultrasound phantoms are invaluable as training tools for vascular access procedures. We developed ultrasound phantoms with wall-less vessels using 3-dimensional printed chambers. Agar was used as a soft tissue-mimicking material, and the wall-less vessels were created with rods that were retracted after the agar was set. The chambers had integrated luer connectors to allow for fluid injections with clinical syringes. Several variations on this design are presented, which include branched and stenotic vessels. The results show that 3-dimensional printing can be well suited to the construction of wall-less ultrasound phantoms, with designs that can be readily customized and shared electronically.

Computational simulation of carotid stenosis and flow dynamics based on patient ultrasound data - A new tool for risk assessment and surgical planning

PURPOSE

There is nowadays extensive experimental and computational investigation on the pathophysiology of atherosclerosis, searching correlations between its focal nature and local hemodynamic environment. The goal of this work is to present a methodology for patient-specific hemodynamics study of the carotid artery bifurcation based on the use of ultrasound (US) morphological and blood flow velocity patient data.

MATERIALS/METHODS

Subject-specific studies were performed for two patients, using a developed finite element code. Geometrical models were obtained from the acquisition of longitudinal and sequential cross-sectional ultrasound images and boundary conditions from Doppler velocity measurements at the common carotid artery.

RESULTS

There was a good agreement between ultrasound imaging data and computational simulated results. For a normal and a stenosed carotid bifurcation the velocity, wall shear stress (WSS) and WSS descriptors analysis illustrated the extremely complex hemodynamic behavior along the cardiac cycle. Different patterns were found, associated with morphology and hemodynamic patient-specific conditions. High values of time-averaged WSS (TAWSS) were found at stenosis site and for both patients TAWSS fields presented low values within areas of high oscillating shear index and relative residence time values, corresponding to recirculation zones.

CONCLUSION

Simulated hemodynamic parameters were able to capture the disturbed flow conditions in a normal and a stenosed carotid artery bifurcation, which play an important role in the development of local atherosclerotic plaques. Computational simulations based on clinic US might help improving diagnostic and treatment management of carotid atherosclerosis.

Manufacturing of microcirculation phantoms using rapid prototyping technologies

In this paper, we describe a method for the manufacturing of a microcirculation phantom that may be used to investigate hemodynamics using optics based methods. We made an Acrylonitrile Butadiene Styrene (ABS) negative mold, manufactured in a Fused Deposition Modelling (FDM) printer, embedded it in Polydimethysilioxane (PDMS) and dissolved it from within using acetone. We successfully made an enlarged three-dimensional (3D) network of microcirculation, and tested it using red blood cell (RBC) analogues. This phantom may be used for testing medical imaging technology.

Poly(vinyl alcohol) gel ultrasound phantom with durability and visibility of internal flow

PURPOSE

Among various existing flow phantoms, none is characterized by appropriate acoustic, visibility, and durability properties simultaneously. The aim of this study was to develop a durable ultrasound phantom with visibility of the internal flow.

METHODS

Poly(vinyl alcohol) (PVA) gel was chosen as the basic material. The acoustic properties of various PVA gels were measured with 40-MHz ultrasound, the compositions of PVA, dimethyl sulfoxide (DMSO), and glass microbeads being changed, while visually checking the transparency. Wall-less ultrasound flow phantoms with a straight channel 2 mm in diameter were made from PVA gel, and ultrasound B-mode imaging was conducted with blood-mimicking fluid flow.

RESULTS

The acoustic properties of in vivo soft tissue were reproduced by PVA gel with a PVA concentration of 15 mass% and a glass microbead concentration of 2.9 mass% in a solvent of 98 mol% DMSO, showing acoustic properties of 1567 ± 4 m/s and 56 ± 5 dB/cm. The PVA gel was durable with visibility of the flow in the ultrasound phantom. The ultrasound B-mode image of the ultrasound flow phantom showed features approximating those of a mouse carotid artery.

CONCLUSION

A durable PVA gel ultrasound phantom with visibility of the internal flow was developed.

Wall-less flow phantom for high-frequency ultrasound applications

There are currently very few test objects suitable for high-frequency ultrasound scanners that can be rapidly manufactured, have appropriate acoustic characteristics and are suitably robust. Here we describe techniques for the creation of a wall-less flow phantom using a physically robust konjac and carrageenan-based tissue-mimicking material. Vessel dimensions equivalent to those of mouse and rat arteries were achieved with steady flow, with the vessel at a depth of 1.0 mm. We then employed the phantom to briefly investigate velocity errors using pulsed wave Doppler with a commercial preclinical ultrasound system. This phantom will provide a useful tool for testing preclinical ultrasound imaging systems.

acoustic assessment of a konjac–carrageenan tissue-mimicking material aT 5–60 MHZ

The acoustic properties of a robust tissue-mimicking material based on konjac–carrageenan at ultrasound frequencies in the range 5–60 MHz are described. Acoustic properties were characterized using two methods: a broadband reflection substitution technique using a commercially available preclinical ultrasound scanner (Vevo 770, FUJIFILM VisualSonics, Toronto, ON, Canada), and a dedicated high-frequency ultrasound facility developed at the National Physical Laboratory (NPL, Teddington, UK), which employed a broadband through-transmission substitution technique. The mean speed of sound across the measured frequencies was found to be 1551.7 ± 12.7 and 1547.7 ± 3.3 m s21, respectively. The attenuation exhibited a non-linear dependence on frequency, f (MHz), in the form of a polynomial function: 0.009787f2 1 0.2671f and 0.01024f2 1 0.3639f, respectively. The characterization of this tissue-mimicking material will provide reference data for designing phantoms for preclinical systems, which may, in certain applications such as flow phantoms, require a physically more robust tissuemimicking material than is currently available.

A review of Doppler ultrasound quality assurance protocols and test devices

In this paper, an overview of Doppler ultrasound quality assurance (QA) testing will be presented in three sections. The first section will review the different Doppler ultrasound parameters recommended by professional bodies for use in QA protocols. The second section will include an evaluation and critique of the main test devices used to assess Doppler performance, while the final section of this paper will discuss which of the wide range of test devices have been found to be most suitable for inclusion in Doppler QA programmes. Pulsed Wave Spectral Doppler, Colour Doppler Imaging QA test protocols have been recommended over the years by various professional bodies, including the UK's Institute of Physics and Engineering in Medicine (IPEM), the American Institute for Ultrasound in Medicine (AIUM), and the International Electrotechnical Commission (IEC). However, despite the existence of such recommended test protocols, very few commercial or research test devices exist which can measure the full range of both PW Doppler ultrasound and colour Doppler imaging performance parameters, particularly quality control measurements such as: (i) Doppler sensitivity (ii) colour Doppler spatial resolution (iii) colour Doppler temporal resolution (iv) colour Doppler velocity resolution (v) clutter filter performance and (vi) tissue movement artefact suppression. In this review, the merits of the various commercial and research test devices will be considered and a summary of results obtained from published studies which have made use of some of these Doppler test devices, such as the flow, string, rotating and belt phantom, will be presented.

Wall motion in the stenotic carotid artery: association with greyscale plaque characteristics, the degree of stenosis and cerebrovascular symptoms

Background

Systolic dilation of the atherosclerotic carotid artery depends on several factors including arterial compliance and the haemodynamic environment. The purpose of this study was to quantify wall motion in stenotic carotid arteries and investigate any associations with the ultrasound greyscale plaque characteristics, the degree of stenosis, and the presence of cerebrovascular symptoms.

Methods

Variations in the lumen diameters of 61 stenotic carotid arteries (stenosis range 10%-95%) from 47 patients were measured before the proximal shoulder of the atherosclerotic plaque using ultrasound image sequences over several cardiac cycles. Absolute and percentage diameter changes from diastole to systole were calculated and their relationship to the degree of stenosis, greyscale plaque characteristics, and the presence of ipsilateral hemispheric symptoms were studied.

Results

The mean absolute diameter change from diastole to systole was 0.45 mm (s.d. 0.17), and the mean percentage diameter change was 6.9% (s.d. 3.1%). Absolute and percentage diameter changes did not have a statistically significant relationship to the degree of stenosis, greyscale plaque characteristics, or the presence of ipsilateral hemispheric symptoms (p > 0.05). Parameters significantly correlated with the presence of symptoms were the degree of stenosis (p = 0.01), plaque greyscale median (p = 0.02) and the plaque surface irregularity index (p = 0.02).

Conclusions

Our study confirmed the degree of stenosis, plaque greyscale median and our surface irregularity index were significant predictors of symptoms, but found no significant correlation between diameter changes of stenosed carotid arteries and the presence of ipsilateral hemispheric symptoms.

Design of anthropomorphic flow phantoms based on rapid prototyping of compliant vessel geometries

Anatomically realistic flow phantoms are essential experimental tools for vascular ultrasound. Here we describe how these flow phantoms can be efficiently developed via a rapid prototyping (RP) framework that involves direct fabrication of compliant vessel geometries. In this framework, anthropomorphic vessel models were drafted in computer-aided design software, and they were fabricated using stereolithography (one type of RP). To produce elastic vessels, a compliant photopolymer was used for stereolithography. We fabricated a series of compliant, diseased carotid bifurcation models with eccentric stenosis (50%) and plaque ulceration (types I and III), and they were used to form thin-walled flow phantoms by coupling the vessels to an agar-based tissue-mimicking material. These phantoms were found to yield Doppler spectrograms with significant spectral broadening and color flow images with mosaic patterns, as typical of disturbed flow under stenosed and ulcerated disease conditions. Also, their wall distension behavior was found to be similar to that observed in vivo, and this corresponded with the vessel wall's average elastic modulus (391 kPa), which was within the nominal range for human arteries. The vessel material's acoustic properties were found to be sub-optimal: the estimated average acoustic speed was 1801 m/s, and the attenuation coefficient was 1.58 dB/(mm·MHz(n)) with a power-law coefficient of 0.97. Such an acoustic mismatch nevertheless did not notably affect our Doppler spectrograms and color flow image results. These findings suggest that phantoms produced from our design framework have the potential to serve as ultrasound-compatible test beds that can simulate complex flow dynamics similar to those observed in real vasculature.

Development of a vessel-mimicking material for use in anatomically realistic Doppler flow phantoms

Polyvinyl alcohol cryogel (PVA-C) is presented as a vessel-mimicking material for use in anatomically realistic Doppler flow phantoms. Three different batches of 10% wt PVA-C containing (i) PVA-C alone, (ii) PVA-C with antibacterial agent and (iii) PVA-C with silicon carbide particles were produced, each with 1-6 freeze-thaw cycles. The resulting PVA-C samples were characterized acoustically (over a range 2.65 to 10.5 MHz) and mechanically to determine the optimum mixture and preparation for mimicking the properties of healthy and diseased arteries found in vivo. This optimum mix was reached with the PVA-C with antibacterial agent sample, prepared after two freeze/thaw cycles, which achieved a speed of sound of 1538 ± 5 m s(-1) and a Young's elastic modulus of 79 ± 11 kPa. This material was used to make a range of anatomically realistic flow phantoms with varying degrees of stenoses, and subsequent flow experiments revealed that higher degrees of stenoses and higher velocities could be achieved without phantom rupturing compared with a phantom containing conventional wall-less vessels.

Validation of endoscopic ultrasound measured flow rate in the azygos vein using a flow phantom

Increase in flow rate within the azygos vein may be used as an indicator of the degree of liver cirrhosis. The aim of this study was to evaluate the error in measurement of flow rate using a commercial endoscopic ultrasound system, using a flow phantom that mimicked azygos vein depth, diameter and flow rate. Diameter was underestimated in all cases, with an average underestimation of 0.09 cm. Maximum velocity was overestimated, by 4 ± 4% at 50°, 11 ± 3% at 60° and 23 ± 7% at 70°. The increase in error with beam-vessel angle is consistent with the error as arising from geometric spectral broadening. Flow was underestimated by amounts up to 33%, and it is noted that the overestimation caused by geometric spectral broadening is in part compensated by underestimation of diameter. It was concluded that measurement of flow rate using a commercially available endoscopic ultrasound system is dependent on the beam-vessel angle, with errors up to 33% for typical vessel depths, diameter and beam-vessel angle.

Development of a range of anatomically realistic renal artery flow phantoms

Computer-aided modelling techniques were used to generate a range of anatomically realistic phantoms of the renal artery from medical images of a 64-slice CT data set acquired from a healthy volunteer. From these data, models of a normal healthy renal artery and diseased renal arteries with 30%, 50%, 70% and 85% stenoses were generated. Investment casting techniques and a low melting point alloy were used to create the vessels with varying degrees of stenosis. The use of novel inserts significantly reduced the time, materials and cost required in the fabrication of these anatomically realistic phantoms. To prevent residual metal remaining in the final phantom lumens a technique employing clingfilm was used to remove all molten metal from the lumen. These novel flow phantoms developed using efficient methods for producing vessels with various degrees of stenosis can provide a means of evaluation of current and emerging ultrasound technology.

A review of tissue substitutes for ultrasound imaging

The characterization and calibration of ultrasound imaging systems requires tissue-mimicking phantoms with known acoustic properties, dimensions and internal features. Tissue phantoms are available commercially for a range of medical applications. However, commercial phantoms may not be suitable in ultrasound system design or for evaluation of novel imaging techniques. It is often desirable to have the ability to tailor acoustic properties and phantom configurations for specific applications. A multitude of tissue-mimicking materials and phantoms are described in the literature that have been created using a variety of materials and preparation techniques and that have modeled a range of biological systems. This paper reviews ultrasound tissue-mimicking materials and phantom fabrication techniques that have been developed over the past four decades, and describes the benefits and disadvantages of the processes. Both soft tissue and hard tissue substitutes are explored.

Acquisition of 3-D arterial geometries and integration with computational fluid dynamics

A system for acquisition of 3-D arterial ultrasound geometries and integration with computational fluid dynamics (CFD) is described. The 3-D ultrasound is based on freehand B-mode imaging with positional information obtained using an optical tracking system. A processing chain was established, allowing acquisition of cardiac-gated 3-D data and segmentation of arterial geometries using a manual method and a semi-automated method, 3D meshing and CFD. The use of CFD allowed visualization of flow streamlines, 2-D velocity contours and 3-D wall shear stress. Three-dimensional positional accuracy was 0.17-1.8mm, precision was 0.06-0.47mm and volume accuracy was 4.4-15%. Patients with disease and volunteers were scanned, with data collection from one or more of the carotid bifurcation, femoral bifurcation and abdominal aorta. An initial comparison between a manual segmentation method and a semi-automated method suggested some advantages to the semi-automated method, including reduced operator time and the production of smooth surfaces suitable for CFD, but at the expense of over-smoothing in the diseased region. There were considerable difficulties with artefacts and poor image quality, resulting in 3-D geometry data that was unsuitable for CFD. These artefacts were exacerbated in disease, which may mean that future effort, in the integration of 3-D arterial geometry and CFD for clinical use, may best be served using alternative 3-D imaging modalities such as magnetic resonance imaging and computed tomography.

A dual-phantom system for validation of velocity measurements in stenosis models under steady flow

A dual-phantom system is developed for validation of velocity measurements in stenosis models. Pairs of phantoms with identical geometry and flow conditions are manufactured, one for ultrasound and one for particle image velocimetry (PIV). The PIV model is made from silicone rubber, and a new PIV fluid is made that matches the refractive index of 1.41 of silicone. Dynamic scaling was performed to correct for the increased viscosity of the PIV fluid compared with that of the ultrasound blood mimic. The degree of stenosis in the models pairs agreed to less than 1%. The velocities in the laminar flow region up to the peak velocity location agreed to within 15%, and the difference could be explained by errors in ultrasound velocity estimation. At low flow rates and in mild stenoses, good agreement was observed in the distal flow fields, excepting the maximum velocities. At high flow rates, there was considerable difference in velocities in the poststenosis flow field (maximum centreline differences of 30%), which would seem to represent real differences in hydrodynamic behavior between the two models. Sources of error included: variation of viscosity because of temperature (random error, which could account for differences of up to 7%); ultrasound velocity estimation errors (systematic errors); and geometry effects in each model, particularly because of imperfect connectors and corners (systematic errors, potentially affecting the inlet length and flow stability). The current system is best placed to investigate measurement errors in the laminar flow region rather than the poststenosis turbulent flow region.

Doppler ultrasound compatible plastic material for use in rigid flow models

A technique for the rapid but accurate fabrication of multiple flow phantoms with variations in vascular geometry would be desirable in the investigation of carotid atherosclerosis. This study demonstrates the feasibility and efficacy of implementing numerically controlled direct-machining of vascular geometries into Doppler ultrasound (DUS)-compatible plastic for the easy fabrication of DUS flow phantoms. Candidate plastics were tested for longitudinal speed of sound (SoS) and acoustic attenuation at the diagnostic frequency of 5 MHz. Teflon was found to have the most appropriate SoS (1376 +/- 40 m s(-1) compared with 1540 m s(-1) in soft tissue) and thus was selected to construct a carotid bifurcation flow model with moderate eccentric stenosis. The vessel geometry was machined directly into Teflon using a numerically controlled milling technique. Geometric accuracy of the phantom lumen was verified using nondestructive micro-computed tomography. Although Teflon displayed a higher attenuation coefficient than other tested materials, Doppler data acquired in the Teflon flow model indicated that sufficient signal power was delivered throughout the depth of the vessel and provided comparable velocity profiles to that obtained in the tissue-mimicking phantom. Our results indicate that Teflon provides the best combination of machinability and DUS compatibility, making it an appropriate choice for the fabrication of rigid DUS flow models using a direct-machining method.

Simulation and validation of arterial ultrasound imaging and blood flow

We reviewed the simulation and validation of arterial ultrasound imaging and blood flow assessment. The physical process of ultrasound imaging and measurement is complex, especially in disease. Simulation of physiological flow in a phantom with tissue equivalence of soft tissue, vessel wall and blood is now achievable. Outstanding issues are concerned with production of anatomical models, simulation of arterial disease, refinement of blood mimics to account for non-Newtonian behavior and validation of velocity measurements against an independent technique such as particle image velocimetry. String and belt phantoms offer simplicity of design, especially for evaluation of velocity estimators, and have a role as portable test objects. Electronic injection and vibrating test objects produce nonphysiologic Doppler signals, and their role is limited. Computational models of the ultrasound imaging and measurement process offer considerable flexibility in their ability to alter multiple parameters of both the propagation medium and ultrasound instrument. For these models, outstanding issues are concerned with the inclusion of different tissue types, multilayer arteries, inhomogeneous tissues and diseased tissues.

Anatomical flow phantoms of the nonplanar carotid bifurcation, part I: computer-aided design and fabrication

Doppler ultrasound is widely used in the diagnosis and monitoring of arterial disease. Current clinical measurement systems make use of continuous and pulsed ultrasound to measure blood flow velocity; however, the uncertainty associated with these measurements is great, which has serious implications for the screening of patients for treatment. Because local blood flow dynamics depend to a great extent on the geometry of the affected vessels, there is a need to develop anatomically accurate arterial flow phantoms with which to assess the accuracy of Doppler blood flow measurements made in diseased vessels. In this paper, we describe the computer-aided design and manufacturing (CAD-CAM) techniques that we used to fabricate anatomical flow phantoms based on images acquired by time-of-flight magnetic resonance imaging (TOF-MRI). Three-dimensional CAD models of the carotid bifurcation were generated from data acquired from sequential MRI slice scans, from which solid master patterns were made by means of stereolithography. Thereafter, an investment casting procedure was used to fabricate identical flow phantoms for use in parallel experiments involving both laser and Doppler ultrasound measurement techniques.