Flow patterns in an endovascular stent-graft for abdominal aortic aneurysm repair

Customized stent-grafts for endovascular aneurysm repair with challenging necks: A numerical proof of concept

Endovascular aortic repair (EVAR) is a challenging intervention whose long-term success strongly depends on the appropriate stent-graft (SG) selection and sizing. Most off-the-shelf SGs are straight and cylindrical. Especially in challenging vessel morphologies, the morphology of off-the-shelf SGs is not able to meet the patient-specific demands. Advanced manufacturing technologies facilitate the development of highly customized SGs. Customized SGs that have the same morphology as the luminal vessel surface could considerably improve the quality of the EVAR outcome with reduced likelihoods of EVAR related complications such as endoleaks type I and SG migration. In this contribution, we use an in silico EVAR methodology that approximates the deployed state of the elastically deformable SG in a hyperelastic, anisotropic vessel. The in silico EVAR results of off-the-shelf SGs and customized SGs are compared qualitatively and quantitatively in terms of mechanical and geometrical parameters such as stent stresses, contact tractions, SG fixation forces and the SG-vessel attachment. In a numerical proof of concept, eight different vessel morphologies, such as a conical vessel, a barrel shaped vessel and a curved vessel, are used to demonstrate the added value of customized SGs compared to off-the-shelf SGs. The numerical investigation has shown large benefits of the highly customized SGs compared to off-the-shelf SGs with respect to a better SG-vessel attachment and a considerable increase in SG fixation forces of up to 50% which indicate decreased likelihoods of EVAR related complications. Hence, this numerical proof of concept motivates further research and development of highly customized SGs for the use in challenging vessel morphologies.

A computational assessment of the hemodynamic effects of crossed and non-crossed bifurcated stent-graft devices for the treatment of abdominal aortic aneurysms

There are several issues attributed with abdominal aortic aneurysm endovascular repair. The positioning of bifurcated stent-grafts (SG) may affect SG hemodynamics. The hemodynamics and geometrical parameters of crossing or non-crossing graft limbs have not being totally accessed. Eight patient-specific SG devices and four pre-operative cases were computationally simulated, assessing the hemodynamic and geometrical effects for crossed (n= 4) and non-crossed (n= 4) configurations. SGs eliminated the occurrence of significant recirculations within the sac prior treatment. Dean's number predicted secondary flow locations with the greatest recirculations occurring at the outlets especially during the deceleration phase. Peak drag force varied from 3.9 to 8.7N, with greatest contribution occurring along the axial and anterior/posterior directions. Average resultant drag force was 20% smaller for the crossed configurations. Maximum drag force orientation varied from 1.4° to 51°. Drag force angle varied from 1° to 5° during one cardiac cycle. 44% to 62% of the resultant force acted along the proximal centerline where SG migration is most likely to occur. The clinician's decision for SG positioning may be a critical parameter, and should be considered prior to surgery. All crossed SG devices had an increased spiral flow effect along the distal legs with reductions in drag forces.

Changes in Coronary Flow Reserve following Stent Implantation in the Swine Descending Thoracic Aorta

Purpose:

To evaluate coronary flow reserve (CFR) changes following stent implantation in the descending thoracic aorta (DTA) of a porcine model.

Methods:

Six pigs (3 males; 40 to 44 kg) were anesthetized and kept on mechanical ventilation. A 6-F guiding right Judkins catheter was advanced under fluoroscopy to the right coronary artery, and a pressure wire with a temperature sensor was placed within the vessel lumen at a distance of 4 cm from the ostium. CFR was estimated by the thermodilution method before and after maximal coronary vasodilation with 20 mg of intracoronary papaverine. Aortography was also performed to measure aortic diameter. Subsequently, a self-expanding vascular stent was deployed into the DTA just below the left subclavian artery (LSA), and CFR was measured again. All animals were maintained for 3 weeks; at the end of this period, a further CFR was calculated using the same procedure.

Results:

The mean aortic diameter below the LSA was 12.15±0.15 mm. Following stent deployment, the mean aortic diameter measured at the stented segment was 12.58±0.11 (p=0.001 versus baseline). The mean CFR value was 4.7062.00 before stent implantation, 2.6860.86 immediately after, and 4.0561.15 at 3 weeks after stenting. Accordingly, CFR values were significantly depressed immediately after stent placement compared with baseline (p=0.027). However, CFR values obtained 3 weeks following stent deployment were similar to the initial values (p=0.59).

Conclusion:

Stent deployment in the normal swine DTA produces a significant immediate decrease in CFR, which is attenuated 3 weeks later. The clinical impact of CFR changes following DTA endografting remain to be elucidated.

A Novel Attempt to Standardize Results of CFD Simulations Basing on Spatial Configuration of Aortic Stent-Grafts

Currently, studies connected with Computational Fluid Dynamic (CFD) techniques focus on assessing hemodynamic of blood flow in vessels in different conditions e.g. after stent-graft’s placement. The paper propose a novel method of standardization of results obtained from calculations of stent-grafts' “pushing forces” (cumulative WSS—Wall Shear Stress), and describes its usefulness in diagnostic process. AngioCT data from 27 patients were used to reconstruct 3D geometries of stent-grafts which next were used to create respective reference cylinders. We made an assumption that both the side surface and the height of a stent-graft and a reference cylinder were equal. The proposed algorithm in conjunction with a stent-graft “pushing forces” on an implant wall, allowed us to determine which spatial configuration of a stent-graft predispose to the higher risk of its migration. For stent-grafts close to cylindrical shape (shape factor φ close to 1) WSS value was about 267Pa, while for stent-grafts different from cylindrical shape (φ close to 2) WSS value was about 635Pa. It was also noticed that deformation in the stent-graft’s bifurcation part impaired blood flow hemodynamic. Concluding the proposed algorithm of standardization proved its usefulness in estimating the WSS values that may be useful in diagnostic process. Angular bends or tortuosity in bifurcations of an aortic implant should be considered in further studies of estimation of the risk of implantation failure.

Outcomes Following Limb Crossing in Endovascular Aneurysm Repairs

Background:

Crossing the limbs of the stent during endovascular aneurysm repair (EVAR) is often used to aid cannulation of the contralateral limb. This study assessed outcomes following the use of this technique.

Methods:

Retrospective review of crossed (n = 43) and uncrossed (n = 269) EVARs was performed at a tertiary vascular center over 5 years. Primary end points were graft limb occlusion (GLO), endoleak, and sac expansion rates. Indications for limb crossing were also assessed.

Results:

Two-year GLO ( P = .34) and type 1 endoleak ( P = .413) rates were similar between groups. Patients undergoing crossed EVAR experienced more type 2 endoleaks ( P = .002) at 24 months but no increase in sac expansion rates was observed ( P = .275). Thirty-day ( P = .57) and late ( P = .268) mortalities were similar between groups. The main indication for limb crossing was distal aortic angulation (48.8%).

Conclusions:

Crossed EVAR does not increase the risk of GLOs or clinically significant endoleaks. Further studies are needed to determine the effect on type 2 endoleak rates.

In-plane mechanics of soft architectured fibre-reinforced silicone rubber membranes

Silicone rubber membranes reinforced with architectured fibre networks were processed with a dedicated apparatus, allowing a control of the fibre content and orientation. The membranes were subjected to tensile loadings combined with continuous and discrete kinematical field measurements (DIC and particle tracking). These tests show that the mechanical behaviour of the membranes is hyperelastic at the first order. They highlight the influence of the fibre content and orientation on both the membrane in-plane deformation and stress levels. They also prove that for the considered fibrous architectures and mechanical loadings, the motion and deformation of fibres is an affine function of the macroscale transformation. These trends are fairly well described by the micromechanical model proposed recently in Bailly et al. (JMBBM, 2012). This result proves that these materials are very good candidates for new biomimetic membranes, e.g. to improve aortic analogues used for in vitro experiments, or existing textiles used for vascular (endo)prostheses.

EXPERIMENTAL RESEARCH OF THE PRESSURE REDUCTION ON AAA WALL BY THE INSERTION OF A STENT GRAFT

The purpose of this study was to investigate the influence of stent grafts on the wall pressure of aneurysms and find out what kind of stent graft is suitable for curing aneurysm. A set of experiment apparatus that simulated the human heart and artery was set up, including an elastic abdominal aortic aneurysm (AAA) model which was made of rubber. The influence of healing induced by stent grafts with different diameters and either permeable or impermeable on the AAA were investigated by comparing experiments using the AAA model with clinical stent grafts in a pulsatile flow system that simulated human blood circulation. The experiment results show that the pressure on the AAA wall reduced after the insertion of a stent graft. The permeable stent graft is not propitious to the pressure reduction. Furthermore, the reduction of pressure is related to stent graft diameter, that is, stent grafts whose diameter is 10–15% larger than the arterial diameter leads to the optimal reduction of the wall pressure. The results are unprecedented and expected to have significant clinical applications.

Hybrid Endografts Combinations for the Treatment of Endoleak in Endovascular Abdominal Aortic Aneurysm Repair

Hybrid endografting in endovascular abdominal aortic aneurysm repair (EVAR) is defined as the process of placing a series of two or more different types of covered stents, usually to treat a complex abdominal aortic aneurysm (AAA) or a primary or secondary endoleak. We describe the treatment of a type III, a type Ib, and a type Ia endoleak in three patients respectively, using hybrid solutions, assembling components from different manufacturers. An update of the current clinical and experimental evidence on the application of anatomically compatible, hybrid endograft systems in conventional EVAR is also provided.

Hemodynamic variations due to spiral blood flow through four patient-specific bifurcated stent graft configurations for the treatment of abdominal aortic aneurysms

Endovascular repair is now a recognised procedure for treating abdominal aortic aneurysms. However, post-operative complications such as stent graft migration and thrombus may still occur. To assess these complications numerically, the correct input boundary conditions, which include the full human aorta with associated branching, should be included. Four patient-specific computed tomography scanned bifurcated stent grafts (SGs) were modelled and attached onto a full human aorta, which included the ascending, aortic arch and descending aortas. Two of the SG geometries had a twisted leg configuration, while the other two had conventional nontwisted leg configurations. Computational fluid dynamics was completed for both geometries and the hemodynamics assessed. The complexity of the flow patterns and secondary flows were influenced by the inclusion of the full human aorta at the SG proximal section. During the decelerating phase significant recirculations occurred along the main body of all SG configurations. The inclusion of the full human aorta did not impact the velocity contours within the distal legs and there was no difference in drag forces with the SG containing the full human aorta and those without. A twisted leg configuration further promoted a spiral flow formation along its distal legs.

Abdominal aortic aneurysm: Treatment options, image visualizations and follow-up procedures

Abdominal aortic aneurysm is a common vascular disease that affects elderly population. Open surgical repair is regarded as the gold standard technique for treatment of abdominal aortic aneurysm, however, endovascular aneurysm repair has rapidly expanded since its first introduction in 1990s. As a less invasive technique, endovascular aneurysm repair has been confirmed to be an effective alternative to open surgical repair, especially in patients with co-morbid conditions. Computed tomography (CT) angiography is currently the preferred imaging modality for both preoperative planning and post-operative follow-up. 2D CT images are complemented by a number of 3D reconstructions which enhance the diagnostic applications of CT angiography in both planning and follow-up of endovascular repair. CT has the disadvantage of high cummulative radiation dose, of particular concern in younger patients, since patients require regular imaging follow-ups after endovascular repair, thus, exposing patients to repeated radiation exposure for life. There is a trend to change from CT to ultrasound surveillance of endovascular aneurysm repair. Medical image visualizations demonstrate excellent morphological assessment of aneurysm and stent-grafts, but fail to provide hemodynamic changes caused by the complex stent-graft device that is implanted into the aorta. This article reviews the treatment options of abdominal aortic aneurysm, various image visualization tools, and follow-up procedures with use of different modalities including both imaging and computational fluid dynamics methods. Future directions to improve treatment outcomes in the follow-up of endovascular aneurysm repair are outlined.

Impact of an aortic nitinol stent graft on flow measurements by time-resolved three-dimensional velocity-encoded MRI

RATIONALE AND OBJECTIVES

Three-dimensional (3D) velocity-encoded cine (VEC) magnetic resonance imaging (MRI) has the potential to quantify 3D hemodynamic aspects known from computational fluid dynamics and to be used to identify hemodynamic risk factors for complications of endovascular aortic repair. The purpose of this study was to investigate the impact of an aortic nickel-titanium (nitinol) stent graft on the accuracy of flow measurements by 3D VEC MRI.

MATERIALS AND METHODS

A pump generated pulsatile aortic flow in an elastic tube phantom mimicking the aorta. Stacked two-dimensional three-directional VEC MRI (stacked-2D-3dir-MRI), 3D three-directional VEC MRI (3D-3dir-MRI), and gold-standard 2D through-plane VEC MRI were applied before and after the insertion of an aortic nitinol stent graft. Six equidistant levels were analyzed twice by the same reader. The percentage difference of the measured flow rate from the gold standard was defined as the parameter of accuracy.

RESULTS

The overall accuracy of in-stent flow measurements related to the gold standard was -5.4% for stacked-2D-3dir-MRI and -4.1% for 3D-3dir-MRI, demonstrating significant overall underestimation compared to the gold standard (P = .016 and P = .013). However, flow measurements with the stent graft were significantly overestimated by 4.1% using stacked-2D-3dir-MRI (P < .001) and by 5.4% using 3D-3dir-MRI (P = .003) compared to identical measurements without the stent graft. In stacked-2D-3dir-MRI, this positive bias was significantly greater at the proximal and distal ends of the stent graft (P = .025). In 3D-3dir-MRI, measurements along the whole length of the stent graft were affected (P = .006). Intraobserver agreement was excellent, with intraclass correlation coefficients of 0.94 for stacked-2D-3dir-MRI (P < .001) and 0.90 for 3D-3dir-MRI (P < .001).

CONCLUSIONS

Flow measurements within an aortic nitinol stent graft by 3D VEC MRI are feasible, but stent grafts may cause a significant positive bias.

In vitro validation of flow measurements in an aortic nitinol stent graft by velocity-encoded MRI

PURPOSE

To validate flow measurements within an aortic nickel-titanium (nitinol) stent graft using velocity-encoded cine magnetic resonance imaging (VEC MRI) and to assess intraobserver agreement of repeated flow measurements.

MATERIALS AND METHODS

An elastic tube phantom mimicking the descending aorta was developed with the possibility to insert an aortic nitinol stent graft. Different flow patterns (constant, sinusoidal and pulsatile aortic flow) were applied by a gear pump. A two-dimensional phase-contrast sequence was used to acquire VEC perpendicular cross-sections at six equidistant levels along the phantom. Each acquisition was performed twice with and without stent graft, and each dataset was analysed twice by the same reader. The percental difference of the measured flow volume to the gold standard (pump setting) was defined as the parameter for accuracy. Furthermore, the intraobserver agreement was assessed.

RESULTS

Mean accuracy of flow volume measurements was -0.45±1.63% without stent graft and -0.18±1.45% with stent graft. Slightly lower accuracy was obtained for aortic flow both without (-2.31%) and with (-1.29%) stent graft. Accuracy was neither influenced by the measurement position nor by repeated acquisitions. There was significant intraobserver agreement with an intraclass correlation coefficient of 0.87 (without stent graft, p<0.001) and 0.80 (with stent graft, p<0.001). The coefficient of variance was 0.25% without stent graft and 0.28% with stent graft.

CONCLUSION

This study demonstrated high accuracy and excellent intraobserver agreement of flow measurements within an aortic nitinol stent graft using VEC MRI. VEC MRI may give new insights into the haemodynamic consequences of endovascular aortic repair.

Engineering silicone rubbers for in vitro studies: creating AAA models and ILT analogues with physiological properties

In vitro studies of abdominal aortic aneurysm (AAA) have been widely reported. Frequently mock artery models with intraluminal thrombus (ILT) analogs are used to mimic the in vivo AAA. While the models used may be physiological, their properties are frequently either not reported or investigated. This study is concerned with the testing and characterization of previously used vessel analog materials and the development of new materials for the manufacture of AAA models. These materials were used in conjunction with a previously validated injection molding technique to manufacture AAA models of ideal geometry. To determine the model properties (stiffness (beta) and compliance), the diameter change of each AAA model was investigated under incrementally increasing internal pressures and compared with published in vivo studies to determine if the models behaved physiologically. A FEA study was implemented to determine if the pressure-diameter change behavior of the models could be predicted numerically. ILT analogs were also manufactured and characterized. Ideal models were manufactured with ILT analog internal to the aneurysm region, and the effect of the ILT analog on the model compliance and stiffness was investigated. The wall materials had similar properties (E(init) 2.22 MPa and 1.57 MPa) to aortic tissue at physiological pressures (1.8 MPa (from literature)). ILT analogs had a similar Young's modulus (0.24 MPa and 0.33 MPa) to the medial layer of ILT (0.28 MPa (from literature)). All models had aneurysm sac compliance (2.62-8.01 x 10(-4)/mm Hg) in the physiological range (1.8-9.4 x 10(-4)/mm Hg (from literature)). The necks of the AAA models had similar stiffness (20.44-29.83) to healthy aortas (17.5+/-5.5 (from literature)). Good agreement was seen between the diameter changes due to pressurization in the experimental and FEA wall models with a maximum difference of 7.3% at 120 mm Hg. It was also determined that the inclusion of ILT analog in the sac of the models could have an effect on the compliance of the model neck. Ideal AAA models with physiological properties were manufactured. The behavior of these models due to pressurization was predicted using finite element analysis, validating this technique for the future design of realistic physiological AAA models. Addition of ILT analogs in the aneurysm sac was shown to affect neck behavior. This could have implications for endovascular AAA repair due to the importance of the neck for stent-graft fixation.

Endovascular stent graft repair of abdominal aortic aneurysms: Current status and future directions

Endovascular stent graft repair of abdominal aortic aneurysm (AAA) has undergone rapid developments since it was introduced in the early 1990s. Two main types of aortic stent grafts have been developed and are currently being used in clinical practice to deal with patients with complicated or unsuitable aneurysm necks, namely, suprarenal and fenestrated stent grafts. Helical computed tomography angiography has been widely recognized as the method of choice for both pre-operative planning and post-operative follow-up of endovascular repair (EVAR). In addition to 2D axial images, a number of 2D and 3D reconstructions are generated to provide additional information about imaging of the stent grafts in relation to the aortic aneurysm diameter and extent, encroachment of stent wires to the renal artery ostium and position of the fenestrated vessel stents. The purpose of this article is to provide an overview of applications of EVAR of AAA and diagnostic applications of 2D and 3D image visualizations in the assessment of treatment outcomes of EVAR. Interference of stent wires with renal blood flow from the hemodynamic point of view will also be discussed, and future directions explored.

Fenestrated stent graft repair of abdominal aortic aneurysm: hemodynamic analysis of the effect of fenestrated stents on the renal arteries

Objective

We wanted to investigate the hemodynamic effect of fenestrated stents on the renal arteries with using a fluid structure interaction method.

Materials and Methods

Two representative patients who each had abdominal aortic aneurysm that was treated with fenestrated stent grafts were selected for the study. 3D realistic aorta models for the main artery branches and aneurysm were generated based on the multislice CT scans from two patients with different aortic geometries. The simulated fenestrated stents were designed and modelled based on the 3D intraluminal appearance, and these were placed inside the renal artery with an intra-aortic protrusion of 5.0-7.0 mm to reflect the actual patients' treatment. The stent wire thickness was simulated with a diameter of 0.4 mm and hemodynamic analysis was performed at different cardiac cycles.

Results

Our results showed that the effect of the fenestrated stent wires on the renal blood flow was minimal because the flow velocity was not significantly affected when compared to that calculated at pre-stent graft implantation, and this was despite the presence of recirculation patterns at the proximal part of the renal arteries. The wall pressure was found to be significantly decreased after fenestration, yet no significant change of the wall shear stress was noticed at post-fenestration, although the wall shear stress was shown to decrease slightly at the proximal aneurysm necks.

Conclusion

Our analysis demonstrates that the hemodynamic effect of fenestrated renal stents on the renal arteries is insignificant. Further studies are needed to investigate the effect of different lengths of stent protrusion with variable stent thicknesses on the renal blood flow, and this is valuable for understanding the long-term outcomes of fenestrated repair.

Type II endoleaks: when is intervention indicated and what is the index of suspicion for types I or III?

One of the principal reasons for failure of endovascular aneurysm repair (EVAR) is the occurrence of endoleaks, which regardless of size or type can transmit systemic pressure to the aneurysm sac. There is little debate that type I endoleaks (poor proximal or distal sealing) are associated with continued risk of aneurysm rupture and require treatment. Similarly, with type III endoleak, there is agreement that the defect in the device needs to be addressed; however, what to do with type II endoleaks and their effect on long-term outcome are not so clear. Aneurysm sac change is a primary parameter for determining the presence of an endoleak and assessing its impact. While diameter measurement has been the most commonly used method for determining sac changes, volume measurement has now been proven superior for monitoring structural changes in the 3-dimensional sac. Determining the source of an endoleak and the direction of flow are necessary for proper classification; however, while computed tomographic angiography has high sensitivity and specificity for detecting endoleaks, it is limited in its ability to show the direction of flow. Contrast-enhanced duplex ultrasound, on the other hand, is better able to quantify flow and characterize endoleaks. Flow is evidence of pressure, and increasing intrasac pressure increases wall tension, thus inducing progressive aneurysm expansion until rupture. Hence, determining intrasac pressure is becoming a vital component of endoleak assessment. All endoleaks can create systemic pressure inside the aneurysm sac, and there are a variety of intrasac pressure transducers being evaluated to assess this effect. A clinical pathway for patients with suspected type II endoleaks is based on a combination of imaging and pressure measurements. Imaging alone requires at least two interval examinations to determine the trend, while pressure measurements give immediate reassurance or an indication to intervene. Although still under development, pressure measurement is destined for general use and will provide a scientific basis for the management of type II endoleaks.

CFD and PTV steady flow investigation in an anatomically accurate abdominal aortic aneurysm

There is considerable interest in computational and experimental flow investigations within abdominal aortic aneurysms (AAAs). This task stipulates advanced grid generation techniques and cross-validation because of the anatomical complexity. The purpose of this study is to examine the feasibility of velocity measurements by particle tracking velocimetry (PTV) in realistic AAA models. Computed tomography and rapid prototyping were combined to digitize and construct a silicone replica of a patient-specific AAA. Three-dimensional velocity measurements were acquired using PTV under steady averaged resting boundary conditions. Computational fluid dynamics (CFD) simulations were subsequently carried out with identical boundary conditions. The computational grid was created by splitting the luminal volume into manifold and nonmanifold subsections. They were filled with tetrahedral and hexahedral elements, respectively. Grid independency was tested on three successively refined meshes. Velocity differences of about 1% in all three directions existed mainly within the AAA sack. Pressure revealed similar variations, with the sparser mesh predicting larger values. PTV velocity measurements were taken along the abdominal aorta and showed good agreement with the numerical data. The results within the aneurysm neck and sack showed average velocity variations of about 5% of the mean inlet velocity. The corresponding average differences increased for all velocity components downstream the iliac bifurcation to as much as 15%. The two domains differed slightly due to flow-induced forces acting on the silicone model. Velocity quantification through narrow branches was problematic due to decreased signal to noise ratio at the larger local velocities. Computational wall pressure and shear fields are also presented. The agreement between CFD simulations and the PTV experimental data was confirmed by three-dimensional velocity comparisons at several locations within the investigated AAA anatomy indicating the feasibility of this approach.

A review of the in vivo and in vitro biomechanical behavior and performance of postoperative abdominal aortic aneurysms and implanted stent-grafts

Endovascular repair of abdominal aortic aneurysms has generated widespread interest since the procedure was first introduced two decades ago. It is frequently performed in patients who suffer from substantial comorbidities that may render them unsuitable for traditional open surgical repair. Although this minimally invasive technique substantially reduces operative risk, recovery time, and anesthesia usage in these patients, the endovascular method has been prone to a number of failure mechanisms not encountered with the open surgical method. Based on long-term results of second- and third-generation devices that are currently becoming available, this study sought to identify the most serious failure mechanisms, which may have a starting point in the morphological changes in the aneurysm and stent-graft. To investigate the "behavior" of the aneurysm after stent-graft repair, i.e., how its length, angulation, and diameter change, we utilized state-of-the-art ex vivo methods, which researchers worldwide are now using to recreate these failure modes.

The analysis and diagnosis of unstable behavior of the blood vessel wall with an aneurysm based on noise science

Previously, one of the authors developed a noninvasive measurement method of acceleration and deceleration during the expansion process of the blood vessel wall under pulsatile pressure flow by measuring the strain rate of the blood vessel wall using a supersonic Doppler effect sensor aided by computer analysis (DPC method). In this paper, on the basis of the analysis of chaos theory, that is, the complexity of science, the unstable behavior of the blood vessel wall with an aneurysm was investigated by identifying the characteristic DPC wave forms induced by the onset and progression of aneurysm. These results showed that unstable dynamic behavior of the blood vessel wall occurs due to the progression of the aneurysm. Furthermore, using the theoretical analysis of chaos, this unstable behavior of the blood vessel wall was quantified and the fundamental principle of a noninvasive diagnostic method of the progressive degree of aneurysm was proposed.

3D multislice CT angiography in post-aortic stent grafting: a pictorial essay

Helical CT angiography has been widely used in both pre- and post-aortic stent grafting and it has been confirmed to be the preferred modality when compared to conventional angiography. The recent development of multislice CT (MSCT) has further enhanced the applications of CT angiography for aortic stent grafting. One of the advantages of MSCT angiography over conventional angiography is that the 3D reconstructions, based on the volumetric CT data, provide additional information during follow-up of aortic stent grafting. While endovascular repair has been increasingly used in clinical practice, the use of 3D MSCT imaging in endovascular repair continues to play an important role. In this pictorial essay, we aimed to discuss the diagnostic performance of 3D MSCT angiography in post aortic stent grafting, including the most commonly used surface shaded display, curvilinear reformation, the maximum intensity projection, volume rendering and virtual endoscopy. The advantages and disadvantages of each 3D reconstruction are also explored.

Computational fluid dynamics: hemodynamic changes in abdominal aortic aneurysm after stent-graft implantation

The aim of this study was to demonstrate quantitatively and qualitatively the hemodynamic changes in abdominal aortic aneurysms (AAA) after stent-graft placement based on multidetector CT angiography (MDCT-A) datasets using the possibilities of computational fluid dynamics (CFD). Eleven patients with AAA and one patient with left-side common iliac aneurysm undergoing MDCT-A before and after stent-graft implantation were included. Based on the CT datasets, three-dimensional grid-based models of AAA were built. The minimal size of tetrahedrons was determined for grid-independence simulation. The CFD program was validated by comparing the calculated flow with an experimentally generated flow in an identical, anatomically correct silicon model of an AAA. Based on the results, pulsatile flow was simulated. A laminar, incompressible flow-based inlet condition, zero traction-force outlet boundary, and a no-slip wall boundary condition was applied. The measured flow volume and visualized flow pattern, wall pressure, and wall shear stress before and after stent-graft implantation were compared. The experimentally and numerically generated streamlines are highly congruent. After stenting, the simulation shows a reduction of wall pressure and wall shear stress and a more equal flow through both external iliac arteries after stenting. The postimplantation flow pattern is characterized by a reduction of turbulences. New areas of high pressure and shear stress appear at the stent bifurcation and docking area. CFD is a versatile and noninvasive tool to demonstrate changes of flow rate and flow pattern caused by stent-graft implantation. The desired effect and possible complications of a stent-graft implantation can be visualized. CFD is a highly promising technique and improves our understanding of the local structural and fluid dynamic conditions for abdominal aortic stent placement.

Endografting of the Descending Thoracic Aorta Increases Ascending Aortic Input Impedance and Attenuates Pressure Transmission in Dogs

OBJECTIVES

Endografting is being used to manage aneurysms, dissections and acute traumatic disruptions of the thoracic aorta. The acute effects of such interventions on ventricular afterload and on pressure wave transmission characteristics are not well known.

METHODS

In five dogs, a 55 mm endograft was introduced into the descending aorta, just distal to the left subclavian artery, with oversizing of 20%. Following formaldehyde induced complete heart block, the hearts were paced (30-120bpm). The ascending aortic pressures and flows were recorded using Millar micro-tip manometers and ultrasonic flowmeters, respectively. Arterial pressures proximal and distal to the stent site were also recorded. For each heart rate, parameters of a modified Windkessel (SVR: systemic vascular resistance, Z0: characteristic impedance, C: total arterial compliance) were estimated. The pulse wave velocity (PWV) and reflection coefficient (Gamma) were calculated from the pressure wave transfer functions.

RESULTS

The Z0 (0.25+/-0.05 vs 0.41+/-0.06 mmHg/ml s(-1), P<.05) was increased and C was decreased (0.45+/-0.07 vs 0.28+/-0.04 ml/mmHg, P<0.001) following endograft placement. SVR tended to increase (P=.06) and ascending aortic Gamma was unchanged. The PWV increased (418+/-67 vs 755+/-135 cm/s, P<.05) and the distal Gamma decreased (0.09+/-0.10 vs -0.49+/-0.07, P<.05).

CONCLUSIONS

Endografting in the proximal descending aorta cause unfavorable changes in the ascending aortic input impedance and an increase in the PWV through the grafted segment, consistent with an increase in the modulus of elasticity. The grafts produce a negative Gamma at the distal end, an uncommon occurrence in the systemic circulation. Whether this change is of sufficient magnitude to result in post-graft dilation is unknown.

Three-dimensional visualization of suprarenal aortic stent-grafts: evaluation of migration in midterm follow-up

PURPOSE

To investigate the midterm results of transrenal fixation of abdominal aortic stent-grafts with regard to device migration and encroachment of stent wires on the renal and visceral branches.

METHODS

Imaging data from 18 patients (15 men; mean age 75 years, range 63-84) undergoing transrenal stent-graft fixation for abdominal aortic aneurysm (AAA) were included in the study. Computed tomographic angiographic data acquired within 1 week of stent-graft implantation were compared to the latest follow-up images. Postprocessing methods generated 3-dimensional (3D) maximum intensity projections (MIP) and virtual intravascular endoscopy (VIE) for evaluation of the relationship between suprarenal stents and aortic branches. Aortic neck angulation was measured in each patient for correlation with the incidence of stent migration.

RESULTS

The mean follow-up period was 40 months. 3D image visualizations showed that the stent-graft moved caudally in all patients (range 2.6-14.2 mm), with migration (>10 mm) observed in 4 (22%) patients. Corresponding VIE images documented changes in stent wire encroachment on the aortic branch ostia in 11 patients, including the number and position of crossing stent wires. There was no close relationship between aortic neck angulation and stent migration.

CONCLUSION

The current study demonstrated that migration occurs at midterm follow-up in transrenally deployed stent-grafts. 3D images were valuable for the assessment of stent migration, as well as its relationship with aortic branch ostia. Long-term follow-up of transrenal fixation deserves to be investigated, especially after observing stent migration relative to aortic ostial encroachment.

Effects of flat, parabolic and realistic steady flow inlet profiles on idealised and realistic stent graft fits through Abdominal Aortic Aneurysms (AAA)

Computational fluid dynamics modelling of bifurcated stent grafts positioned across Abdominal Aortic Aneursysms (AAAs) is influenced significantly by the boundary conditions and geometry. To assess these influencing factors, simulations using three different steady inlet profiles and two geometries were run. The steady velocity inlet profiles (flat, parabolic and realistic) were used as input boundary conditions with a constant pressure outlet for each model. The geometry of an out-of-plane realistic stent graft model, fitted to the internal geometry of an AAA (a realistic geometry generated from CT scans) was compared to an idealised geometry of an in-plane model. It was found that the realistic boundary condition when applied to the idealised model had a 5% difference in outlet flow rates when compared to flat and parabolic inlet profiles, while the realistic models had an 11-16% difference. The blood flowed in a parallel streamlined fashion for all the idealised models with slight recirculation for the realistic boundary condition. All realistic models had significant recirculation and flowed in a left-handed helix motion in the proximal end and left leg and in a right-handed helix motion in the right leg. The drag force was unidirectional in the idealised models, while it was found to act in all three directions for the realistic models with a 26% increase over the idealised models. It was concluded that geometry has the greatest influence on the outlet flow rates, flow patterns and drag forces. Input boundary condition cause variations in the skewness and recirculation of the flow throughout the models.

Analysis of biomechanical factors affecting stent-graft migration in an abdominal aortic aneurysm model

Focusing on a representative abdominal aortic aneurysm (AAA) with a bifurcating stent-graft (SG), a fluid-structure interaction (FSI) solver with user-supplied programs has been employed to solve for blood flow, AAA/SG deformation, sac pressure and wall stresses, as well as the downward forces acting on the SG. Simulation results indicate that implanting a SG can significantly reduce sac pressure, mechanical stress, pulsatile wall motion, and maximum diameter change in AAAs; hence, it may restore normal blood flow and prevent AAA rupture effectively. The transient SG drag force is similar in trend as the cardiac pressure. Its magnitude depends on multi-factors including blood flow conditions, as well as SG and aneurysm geometries. Specifically, AAA neck angle, iliac bifurcation angle, neck aorta-to-iliac diameter ratio, SG size, and blood waveform play important roles in generating a fluid flow force potentially leading to SG migration. It was found that the drag force can exceed 5N for an AAA with a large neck or iliac angle, wide aortic neck and narrow iliac arteries, large SG size, and/or abnormal blood waveform. Thus, the fixation of self-expandable or balloon-expandable SG contact may be inadequate to withstand the forces of blood flowing through the implant and hence means of extra fixation should be considered. A comprehensive FSI analysis of the coupled SG-AAA dynamics provides physical insight for evaluating the luminal hemodynamics, and maximum AAA-stresses as well as biomechanical factors leading potentially to SG migration.

Computational analysis of biomechanical contributors to possible endovascular graft failure

This paper evaluates numerically coupled blood flow and wall structure interactions in a representative stented abdominal aortic aneurysm (AAA) model, leading potentially to endovascular graft (EVG) failure. A total of 12 biomechanical contributors to possible EVG migration were considered. The results show that after EVG insertion for the given model, the peak AAA sac-pressure was reduced to 14.2 mmHg (11.8% of p(lumen)), and hence the maximum von Mises wall stress and wall deformation dropped by factors of 20 and 10, respectively. Thus, an EVG can significantly reduce sac pressure, mechanical stress, pulsatile wall motion, and the maximum diameter in AAAs and hence prevent AAA rupture effectively. In the absence of endoleaks, elevated sac-pressure can still be caused by fluid-structure interactions between the EVG, stagnant blood, and AAA wall. EVG migration forces vary from 1.4 to 7 N for different EVG geometries, material properties, and hemodynamic conditions. AAA-neck angle, iliac bifurcation angle, neck aorta-to-iliac diameter ratio, EVG size, aorto-uni-iliac EVG, and hypertension play important roles in generating forces potentially leading to EVG migration.

Blood flow and structure interactions in a stented abdominal aortic aneurysm model

Since the introduction of endovascular techniques in the early 1990s for the treatment of abdominal aortic aneurysms (AAAs), the insertion of an endovascular graft (EVG) into the affected artery segment has been greatly successful for a certain group of AAA patients and is continuously evolving. However, although minimally invasive endovascular aneurysm repair (EVAR) is very attractive, post-operative complications may occur. Typically, they are the result of excessive fluid-structure interaction dynamics, possibly leading to EVG migration. Considering a 3D stented AAA, a coupled fluid flow and solid mechanics solver was employed to simulate and analyze the interactive dynamics, i.e., pulsatile blood flow in the EVG lumen, pressure levels in the stagnant blood filling the AAA cavity, as well as stresses and displacements in the EVG and AAA walls. The validated numerical results show that a securely placed EVG shields the diseased AAA wall from the pulsatile blood pressure and hence keeps the maximum wall stress 20 times below the wall stress value in the non-stented AAA. The sac pressure is reduced significantly but remains non-zero and transient, caused by the complex fluid-structure interactions between luminal blood flow, EVG wall, stagnant sac blood, and aneurysm wall. The time-varying drag force on the EVG exerted by physiological blood flow is unavoidable, where for patients with severe hypertension the risk of EVG migration is very high.

Transrenal fixation of aortic stent-grafts: current status and future directions

Aortic stent-graft repair has been widely used in clinical practice for more than a decade, achieving satisfactory results compared to open surgical techniques. Transrenal fixation of stent-grafts is designed to obtain secure fixation of the proximal end of the stent-graft to avoid graft migration and to prevent type I endoleak. Unlike infrarenal deployment of stent-grafts, transrenal fixation takes advantage of the relative stability of the suprarenal aorta as a landing zone for the uncovered struts of the proximal stent. These transostial wires have sparked concern about the patency of the renal arteries, interference with renal blood flow, and effects on renal function. Although short to midterm results with suprarenal stent-grafts have not shown significant changes in renal function, long-term effects of this technique are still not fully understood. This review will explore the current status of transrenal fixation of aortic stent-grafts, potential risks of stent struts relative to the renal ostium, alternative methods to preserve blood flow to the renal arteries, and future directions or developments in stent-graft design to prevent myointimal proliferation around the stent struts.