Steady and pulsatile flow fields in an end-to-side arterial anastomosis model

End-to-side Anastomosis on Digital Arteries: Just a Technical Choice or a Real Benefit?

High-quality evidence is currently poor regarding the benefits of end-to-end (ETE) or end-to-side (ETS) anastomosis in arterial and venous anastomoses, despite being postulated as a potential influence on outcomes. A sufficient microvascular anastomosis is indispensable for the success of any free tissue transfer. ETS microvascular anastomoses have been becoming increasingly important as they allow reconstruction even in patients with impaired vascular status. To the authors’ knowledge, no studies have examined the choice of ETE or ETS anastomoses specifically for digital arteries.

Flow patterns through vascular graft models with and without cuffs

The shape of a bypass graft plays an important role on its efficacy. Here, we investigated flow through two vascular graft designs-with and without cuff at the anastomosis. We conducted Digital Particle Image Velocimetry (DPIV) measurements to obtain the flow field information through these vascular grafts. Two pulsatile flow waveforms corresponding to cardiac cycles during the rest and the excitation states, with 10% and without retrograde flow out the proximal end of the native artery were examined. In the absence of retrograde flow, the straight end-to-side graft showed recirculation and stagnation regions that lasted throughout the full cardiac cycle with the stagnation region more pronounced in the excitation state. The contoured end-to-side graft had stagnation region that lasted only for a portion of the cardiac cycle and was less pronounced. With 10% retrograde flow, extended stagnation regions under both rest and excitation states for both bypass grafts were eliminated. Our results show that bypass graft designers need to consider both the type of flow waveform and presence of retrograde flow when sculpting an optimal bypass graft geometry.

Effect of swirling blood flow on vortex formation at post-stenosis

Various clinical observations reported that swirling blood flow is a normal physiological flow pattern in various vasculatures. The swirling flow has beneficial effects on blood circulation through the blood vessels. It enhances oxygen transfer and reduces low-density lipoprotein concentration in the blood vessel by enhancing cross-plane mixing of the blood. However, the fluid-dynamic roles of the swirling flow are not yet fully understood. In this study, inhibition of material deposition at the post-stenosis region by the swirling flow was observed. To reveal the underlying fluid-dynamic characteristics, pathline flow visualization and time-resolved particle image velocimetry measurements were conducted. Results showed that the swirling inlet flow increased the development of vortices at near wall region of the post-stenosis, which can suppress further development of stenosis by enhancing transport and mixing of the blood flow. The fluid-dynamic characteristics obtained in this study would be useful for improving hemodynamic characteristics of vascular grafts and stents in which the stenosis frequently occurred. Moreover, the time-resolved particle image velocimetry measurement technique and vortex identification method employed in this study would be useful for investigating the fluid-dynamic effects of the swirling flow on various vascular environments.

Numerical investigation of blood flow in a deformable coronary bifurcation and non-planar branch

INTRODUCTION

Among cardiovascular diseases, arterials stenosis is recognized more commonly than the others. Hemodynamic characteristics of blood play a key role in the incidence of stenosis. This paper numerically investigates the pulsatile blood flow in a coronary bifurcation with a non-planar branch. To create a more realistic analysis, the wall is assumed to be compliant. Furthermore, the flow is considered to be three-dimensional, incompressible, and laminar.

METHODS

The effects of non-Newtonian blood, compliant walls and different angles of bifurcation on hemodynamic characteristics of flow were evaluated. Shear thinning of blood was simulated with the Carreau-Yasuda model. The current research was mainly focused on the flow characteristics in bifurcations since atherosclerosis occurs mostly in bifurcations. Moreover, as the areas with low shear stresses are prone to stenosis, these areas were identified.

RESULTS

Our findings indicated that the compliant model of the wall, bifurcation's angle, and other physical properties of flow have an impact on hemodynamics of blood flow. Lower wall shear stress was observed in the compliant wall than that in the rigid wall. The outer wall of bifurcation in all models had lower wall shear stress. In bifurcations with larger angles, wall shear stress was higher in outer walls, and lower in inner walls.

CONCLUSION

The non-Newtonian blood vessels and different angles of bifurcation on hemodynamic characteristics of flow evaluation confirmed a lower wall shear stress in the compliant wall than that in the rigid wall, while the wall shear stress was higher in outer walls but lower in inner walls in the bifurcation regions with larger angles.

Fluid-dynamic optimal design of helical vascular graft for stenotic disturbed flow

Although a helical configuration of a prosthetic vascular graft appears to be clinically beneficial in suppressing thrombosis and intimal hyperplasia, an optimization of a helical design has yet to be achieved because of the lack of a detailed understanding on hemodynamic features in helical grafts and their fluid dynamic influences. In the present study, the swirling flow in a helical graft was hypothesized to have beneficial influences on a disturbed flow structure such as stenotic flow. The characteristics of swirling flows generated by helical tubes with various helical pitches and curvatures were investigated to prove the hypothesis. The fluid dynamic influences of these helical tubes on stenotic flow were quantitatively analysed by using a particle image velocimetry technique. Results showed that the swirling intensity and helicity of the swirling flow have a linear relation with a modified Germano number (Gn*) of the helical pipe. In addition, the swirling flow generated a beneficial flow structure at the stenosis by reducing the size of the recirculation flow under steady and pulsatile flow conditions. Therefore, the beneficial effects of a helical graft on the flow field can be estimated by using the magnitude of Gn*. Finally, an optimized helical design with a maximum Gn* was suggested for the future design of a vascular graft.

Novel modular anastomotic valve device for hemodialysis vascular access: preliminary computational hemodynamic assessment

PURPOSE

Arteriovenous graft patency is limited by terminal occlusion caused by intimal hyperplasia (IH). Motivated by evidence that flow disturbances promote IH progression, a modular anastomotic valve device (MAVD) was designed to isolate the graft from the circulation between dialysis periods (closed position) and enable vascular access during dialysis (open position). The objective of this study was to perform a preliminary computational assessment of the device ability to normalize venous flow between dialysis periods and potentially limit IH development and thrombogenesis.

METHODS

Computational fluid dynamics simulations were performed to compare flow and wall shear stress (WSS) in a native vein and MAVD prototypes featuring anastomotic angles of 90° and 30°. Low WSS (LWSS) regions prone to IH development were characterized in terms of temporal shear magnitude (TSM), oscillatory shear index (OSI), and relative residence time (RRT). Thrombogenic potential was assessed by investigating the loading history of fluid particles traveling through the device.

RESULTS

The closed MAVD exhibited the same flow characteristics as the native vein (0.3% difference in pressure drop, 3.5% difference in surface-averaged WSS). The open MAVD generated five LWSS regions (TSM <0.5 Pa) exhibiting different degrees of flow reversal (surface-averaged OSI: 0.03-0.36) and stagnation (max RRT: 2.50-37.16). Reduction in anastomotic angle resulted in the suppression of three LWSS regions and overall reductions in flow reversal (surface-averaged OSI <0.21) and stagnation (max RRT <18.05).

CONCLUSIONS

This study suggests the ability of the MAVD to normalize venous flow between dialysis periods while generating the typical hemodynamics of end-to-side vein-graft anastomoses during dialysis.

NUMERICAL SIMULATION ON THE EFFECTS OF DRUG-ELUTING STENTS WITH DIFFERENT LINKS ON HEMODYNAMICS AND DRUG CONCENTRATION DISTRIBUTION

The changes of hemodynamics and drug distribution caused by the implantation of drug-eluting stents (DES) have a significant influence on the in-stent restenosis. The present study numerically carried out a comparative study of hemodynamics and drug distribution using four different links of DES: Cordis BX velocity (Model A), Jostent flex (Model B), Sorin Carbostent (Model C), and DT-2 (Model D). The results showed that (1) low wall shear stress (WSS) distribution region spread widely in Model C (16.16%), with the least in Model B (10.35%); (2) Model C has relatively uniform drug concentration and causes of fewer low drug concentration region; and (3) Model A has the largest drug concentration, but also the most uneven distribution of drug. It was concluded that DES with circumferential links helps to improve in-stent restenosis as compared with that with longitudinal designs, and flexible links led to more uniformly and smoothly distributed blood flow than rigid links. However, the links with longitudinal designs had a better performance as drug release carrier than that with circumferential design. And if the links are too close together, the drug cannot be released effectively in the blood vessels. The current study helps to enhance our understanding of the performance of DES and provides assistance for optimal design and selection of DES.

CFD simulation of hemodynamics in sequential and individual coronary bypass grafts based on multislice CT scan datasets

There is still controversy over the differences in the patency rates of the sequential and individual coronary artery bypass grafting (CABG) techniques. The purpose of this paper was to non-invasively evaluate hemodynamic parameters using complete 3D computational fluid dynamics (CFD) simulations of the sequential and the individual methods based on the patient-specific data extracted from computed tomography (CT) angiography. For CFD analysis, the geometric model of coronary arteries was reconstructed using an ECG-gated 64-detector row CT. Modeling the sequential and individual bypass grafting, this study simulates the flow from the aorta to the occluded posterior descending artery (PDA) and the posterior left ventricle (PLV) vessel with six coronary branches based on the physiologically measured inlet flow as the boundary condition. The maximum calculated wall shear stress (WSS) in the sequential and the individual models were estimated to be 35.1 N/m(2) and 36.5 N/m(2), respectively. Compared to the individual bypass method, the sequential graft has shown a higher velocity at the proximal segment and lower spatial wall shear stress gradient (SWSSG) due to the flow splitting caused by the side-to-side anastomosis. Simulated results combined with its surgical benefits including the requirement of shorter vein length and fewer anastomoses advocate the sequential method as a more favorable CABG method.

Numerical Simulation of Physiological Blood Flow in 2-way Coronary Artery Bypass Grafts

The Coronary Artery Bypass Graft (CABG) yields excellent results and remains the modern standard of care for treatment of occlusive disease in the cardiovascular system. However, the development of anastomotic Intimal Hyperplasia (IH) and restenosis can compromise the medium-and-long term effects of the CABG. This problem can be correlated with the geometric configuration and hemodynamics of the bypass graft. A novel geometric configuration was proposed for the CABG with two symmetrically implanted grafts for the purpose of improving the hemodynamics. Physiological blood flows in two models of bypass grafts were simulated using numerical methods. One model was for the conventional bypass configuration with a single graft (1-way model); the other model was for the proposed bypass configuration with two grafts (2-way model). The temporal and spatial distributions of hemodynamics, such as flow patterns and Wall Shear Stress (WSS) in the vicinity of the distal anastomoses, were analyzed and compared. Calculation results showed that the 2-way model possessed favorable hemodynamics with uniform longitudinal flow patterns and WSS distributions, which could decrease the probability of restenosis and improve the effect of the surgical treatment. Concerning the limitations of the 2-way bypass grafts, it is necessary to perform animal experiments to verify the viability of this novel idea for the CABG.

Hemodynamic characteristics of the vertebrobasilar system analyzed using MRI-based models

The vertebrobasilar system (VBS) is unique in human anatomy in that two arteries merge into a single vessel, and it is especially important because it supplies the posterior circulation of the brain. Atherosclerosis develops in this region, and atherosclerotic plaques in the vertebrobasilar confluence can progress with catastrophic consequences, including artery occlusion. Quantitative assessments of the flow characteristics in the VBS could elucidate the factors that influence flow patterns in this confluence, and deviations from normal patterns might then be used to predict locations to monitor for potential pathological changes, to detect early signs of disease, and to evaluate treatment options and efficacy. In this study, high-field MRI was used in conjunction with computational fluid dynamics (CFD) modeling to investigate the hemodynamics of subject-specific confluence models (n = 5) and to identify different geometrical classes of vertebrobasilar systems (n = 12) of healthy adult subjects. The curvature of the vessels and their mutual orientation significantly affected flow parameters in the VBS. The basilar artery geometry strongly influenced both skewing of the velocity profiles and the wall shear stress distributions in the VBS. All five subjects modeled possessed varying degrees of vertebral asymmetry, and helical flow was observed in four cases, suggesting that factors other than vertebral asymmetry influence mixing of the vertebral artery flow contributions. These preliminary studies verify that quantitative, MR imaging techniques in conjunction with subject-specific CFD models of healthy adult subjects may be used to characterize VBS hemodynamics and to predict flow features that have been related to the initiation and development of atherosclerosis in large arteries. This work represents an important first step towards applying this approach to study disease initiation and progression in the VBS.

Initial temporary vascular insufficiency in latissimus dorsi and thoracodorsal perforator flaps

BACKGROUND

Initial temporary vascular insufficiency of the perforator flap is confused with real flap ischemia or congestion during the initial period of reconstruction. Latissimus dorsi and thoracodorsal perforator flaps are no exception. Since a reliable perforator is not always consistent in its location or diameter, and recipient vessels may not always be healthy, the vascular pedicle is frequently spastic or the flap is readily congested. Risk factors were reviewed and several preparations were necessary.

METHODS

In a preliminary study, 73 patients undergoing reconstruction with a latissimus dorsi or thoracodorsal perforator flap were retrospectively reviewed. Temporary flap congestion was observed in 10 patients (13.7 percent), and six risk factors were identified. To alleviate flap congestion, four supplementary measures were prepared for patients with risk factors: T-anastomosis for the flow dispersion, inclusion of an additional vein, inclusion of a supercharged perforator, and a muscle-sparing technique.

RESULTS

Flap congestion was observed in two of 32 patients (6.3 percent); there was no marginal necrosis. T-anastomosis was the most commonly prepared measure. An additional draining vein or a supercharged perforator was frequently used in large, thin, or relatively long flaps, and a muscle-sparing technique was used for flaps based on a less reliable perforator.

CONCLUSIONS

Perforator selection and careful dissection of the pedicle are required for successful reconstruction in latissimus dorsi or thoracodorsal perforator flaps. A perforator pedicle is more sensitive than a conventional flap, and flap congestion is a concern in patients with risk factors, even though most cases are relieved in time. To prevent congestion, the appropriate flap design with preparation of supplementary measures is recommended for better results when the flap is elevated.

Flow studies in three-dimensional aorto-right coronary bypass graft system

This paper presents the fluid dynamics of blood flow in a coronary bypass model of the aorto-right coronary bypass system. Three-dimensional computational fluid dynamic simulations are developed of the blood flow in coronary artery-bypass systems, using the computational fluid dynamics software (FLUENT 6.0.1). These blood flow simulations are performed within small intervals of the cardiac cycle, using input data consisting of physiological measurements of flow rates in the aorta, obtained from earlier studies. We have calculated the flow-field distributions of the velocity and the wall shear stress at four typical instants of the cardiac cycle, two during systole and two during the diastole phase. Plots of velocity vector and the wall shear stress are displayed in the aorto-graft-coronary arterial flow-field domain, providing an insight into the link between fluid dynamics and arterial diseases. The prime regions of disturbed flow patterns are at the entrance into the graft from the aorta and at the exit from the graft into the right coronary artery. Our objective is to obtain an understanding of how the coronary artery is perfused by the graft, and thereby into the factors affecting graft patency.

Biomechanics of coronary artery and bypass graft disease: potential new approaches

The contribution of biomechanical factors to the incidence and distribution of coronary artery and bypass graft disease is underrecognized. This review examined the literature to determine which factors were relevant and the evidence for their importance. It identified two primary biomechanical factors that predispose to disease: (1) low-wall shear stress and (2) high-wall mechanical stress or strain. A range of secondary biomechanical factors have also been identified and include: vessel geometry; vessel movement; vessel wall characteristics and the presence of reflection waves. Potential surgical approaches for minimizing these effects are discussed.

Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions

BACKGROUND

The segment of the vein mobilized for arterial anastomosis in the creation of an arteriovenous fistula (AVF) is the swing segment. This segment may experience turbulent flow and altered shear mechanical stress that result in stenosis. We sought to determine the frequency of stenotic lesions in the swing segment.

STUDY DESIGN

Case series.

SETTINGS & PARTICIPANTS

From January 31, 2003, to June 30, 2005, records of all patients referred to an outpatient hemodialysis vascular access center for AVF dysfunction were reviewed (n = 484). Of these, 278 patients had angiographically documented stenosis (any degree of luminal narrowing) on their first visit.

OUTCOMES & MEASUREMENTS

Distribution of stenoses in different segments of the AVF. Swing-segment stenoses were classified as proximal (outflow into axillary vein system), distal or juxta-anastomotic (adjacent to the anastomosis), and the cephalic arch.

RESULTS

Overall prevalence of angiographically documented swing segment stenosis (proximal, distal or juxta-anastomotic, and cephalic arch) was 45.7% (127 of 278 patients), whereas the remaining stenoses (151 of 278 patients) were distributed among the puncture zone, arterial, arterial anastomosis, and central veins. The most frequent location of the swing-segment stenosis was juxta-anatomosis (63%; 80 of 127 patients), followed by cephalic arch (19%; 24 of 127 patients) and proximal swing segment (18%; 23 of 127 patients). The distribution of swing-segment stenosis (n = 127) was equivalent among the various fistulas (brachial-cephalic, 35.4%; radial-cephalic, 33.9%; and brachial-basilic, 30.7%). Eighty-three percent of swing-segment stenoses were significant (>50% luminal narrowing) and underwent percutaneous transluminal angioplasty, with a 93% success rate.

LIMITATIONS

Retrospective nature of the study and potential selection bias.

CONCLUSION

In our population, swing-segment stenosis is the most common lesion in dysfunctional AVFs; juxta-anastomotic stenosis is the predominant lesion independent of fistula type. Whether the occurrence of swing-segment stenosis is caused by mobilization of the vein during surgery is not clear.

Microvascular stress analysis

PURPOSE OF THE STUDY

To develop a finite element model (FEM) to study the effect of the stress and strain, in microvascular anastomoses that result from the geometrical mismatch of anastomosed vessels.

MATERIAL AND METHODS

FEMs of end-to-end and end-to-side anastomoses were constructed. Simulations were made using finite element software (NISA). We investigated the angle of inset in the end-to-side anastomosis and the discrepancy in the size of the opening in the vessel between the host and recipient vessels. The FEMs were used to predict principal and shear stress and strain at the position of each node.

RESULTS

Two types of vascular deformation were predicted during different simulations: longitudinal distortion, and rotational distortion. Stress values ranged from 151.1 to 282.4MPa for the maximum principal stress, from -122.9 to -432.2MPa for the minimum principal stress, and from 122.1 to 333.1MPa for the maximum shear stress. The highest values were recorded when there was a 50% mismatch in the diameter of the vessels at the site of the end-to-end anastomosis.

CONCLUSION

The effect of the vessel's size discrepancy on the blood flow and deformation was remarkable in the end-to-end anastomosis. End-to-side anastomosis was superior to end-to-end anastomosis. FEM is a powerful tool to study vascular deformation, as it predicts deformation and biomechanical processes at sites where physical measurements are likely to remain impossible in living humans.

BIOMECHANICAL CONSIDERATIONS IN THE DESIGN OF GRAFT: THE HOMEOSTASIS HYPOTHESIS

Since its inception in the 1960s, coronary artery bypass graft (CABG) evolved as one of the most common, best documented, and most effective of all major surgical treatments for ischemic heart disease. Despite its widespread use, however, the outcome is not always completely satisfactory. The objective of this review is to highlight the physical determinants of biomechanical design of CABG so that future procedures would have prolonged patency and better outcome. Our central axiom postulates the existence of a mechanical homeostatic state of the blood vessel, i.e., the variation in vessel wall stresses and strains are relatively small under physiological conditions. Any perturbation of mechanical homeostasis leads to growth and remodeling. In this sense, stenosis and failure of a graft may be viewed as an adaptation process gone awry. We outline the principles of engineering design and discuss the biofluid and biosolid mechanics principles that may have the greatest bearing on mechanical homeostasis and the long-term outcome of CABG.

Numerical Simulation of Wall Shear Stress and Particle-Based Hemodynamic Parameters in Pre-Cuffed and Streamlined End-to-Side Anastomoses

A number of research studies have related multiple hemodynamic parameters to the formation of distal anastomotic intimal hyperplasia (IH) at the sub-cellular, cellular, and tissue levels. Focusing on mitigating WSS-based parameters alone, several studies have suggested geometrically modified end-to-side anastomoses with the intent of improving synthetic graft patency rates. However, recent clinical trials of commercially available versions of these grafts indicate persistently high rates of failure. Furthermore, recent evidence suggests that platelet-wall interactions may play a significant role in the formation of IH, which is not captured by WSS-based parameters alone. In this study, numerical simulations have been conducted to assess the potential for IH formation in conventional and geometrically modified anastomoses based on both wall shear stress (WSS) conditions and platelet-wall interactions. Sites of significant particle-wall interactions, including elevated concentrations and stasis, were identified by a near-wall residence time model, which includes factors for platelet activation and surface reactivity. Conventional, pre-cuffed, and streamlined distal end-to-side anastomoses were considered with proximal and distal arterial outflow. It was found that a pre-cuffed anastomosis, similar to the Distaflo configuration, does not offer a hemodynamic advantage over the conventional design considered with respect to the magnitude of the WSS field and the potential for platelet interactions with the vessel surface. Streamlined configurations largely consistent with venous confluences resulted in an advantageous reduction of wall shear stress gradient values; however, particle-wall interactions remained significant throughout the anastomosis. Results of this study are not intended to be directly extrapolated to surgical recommendations. However, these results highlight the difficulty associated with designing an end-to-side distal anastomosis with two-way outflow that is capable of simultaneously reducing multiple hemodynamic parameters. Further testing will be necessary to determine if the observed elevated particle-wall interactions in a pre-cuffed anastomosis provide the stimulus responsible for the reported high failure rates of these grafts.

Fluid flow structure in arterial bypass anastomosis

The fluid flow through a stenosed artery and its bypass graft in an anastomosis can substantially influence the outcome of bypass surgery. To help improve our understanding of this and related issues, the steady Navier-Stokes flows are computed in an idealized arterial bypass system with partially occluded host artery. Both the residual flow issued from the stenosis--which is potentially important at an earlier stage after grafting--and the complex flow structure induced by the bypass graft are investigated. Seven geometric models, including symmetric and asymmetric stenoses in the host artery, and two major aspects of the bypass system, namely, the effects of area reduction and stenosis asymmetry, are considered. By analyzing the flow characteristics in these configurations, it is found that (1) substantial area reduction leads to flow recirculation in both upstream and downstream of the stenosis and in the host artery near the toe, while diminishes the recirculation zone in the bypass graft near the bifurcation junction, (2) the asymmetry and position of the stenosis can affect the location and size of these recirculation zones, and (3) the curvature of the bypass graft can modify the fluid flow structure in the entire bypass system.

Local and Global Geometric Influence on Steady Flow in Distal Anastomoses of Peripheral Bypass Grafts

We consider the effect of geometrical configuration on the steady flow field of representative geometries from an in vivo anatomical data set of end-to-side distal anastomoses constructed as part of a peripheral bypass graft. Using a geometrical classification technique, we select the anastomoses of three representative patients according to the angle between the graft and proximal host vessels (GPA) and the planarity of the anastomotic configuration. The geometries considered include two surgically tunneled grafts with shallow GPAs which are relatively planar but have different lumen characteristics, one case exhibiting a local restriction at the perianastomotic graft and proximal host whilst the other case has a relatively uniform cross section. The third case is nonplanar and characterized by a wide GPA resulting from the graft being constructed superficially from an in situ vein. In all three models the same peripheral resistance was imposed at the computational outflows of the distal and proximal host vessels and this condition, combined with the effect of the anastomotic geometry, has been observed to reasonably reproduce the in vivo flow split. By analyzing the flow fields we demonstrate how the local and global geometric characteristics influences the distribution of wall shear stress and the steady transport of fluid particles. Specifically, in vessels that have a global geometric characteristic we observe that the wall shear stress depends on large scale geometrical factors, e.g., the curvature and planarity of blood vessels. In contrast, the wall shear stress distribution and local mixing is significantly influenced by morphology and location of restrictions, particular when there is a shallow GPA. A combination of local and global effects are also possible as demonstrated in our third study of an anastomosis with a larger GPA. These relatively simple observations highlight the need to distinguish between local and global geometric influences for a given reconstruction. We further present the geometrical evolution of the anastomoses over a series of follow-up studies and observe how the lumen progresses towards the faster bulk flow of the velocity in the original geometry. This mechanism is consistent with the luminal changes in recirculation regions that experience low wall shear stress. In the shallow GPA anastomoses the proximal part of the native host vessel occludes or stenoses earlier than in the case with wide GPA. A potential contribution to this behavior is suggested by the stronger mixing that characterizes anastomoses with large GPA.

Computational model of blood flow in the aorto-coronary bypass graft

Background

Coronary artery bypass grafting surgery is an effective treatment modality for patients with severe coronary artery disease. The conduits used during the surgery include both the arterial and venous conduits. Long- term graft patency rate for the internal mammary arterial graft is superior, but the same is not true for the saphenous vein grafts. At 10 years, more than 50% of the vein grafts would have occluded and many of them are diseased. Why do the saphenous vein grafts fail the test of time? Many causes have been proposed for saphenous graft failure. Some are non-modifiable and the rest are modifiable. Non-modifiable causes include different histological structure of the vein compared to artery, size disparity between coronary artery and saphenous vein. However, researches are more interested in the modifiable causes, such as graft flow dynamics and wall shear stress distribution at the anastomotic sites. Formation of intimal hyperplasia at the anastomotic junction has been implicated as the root cause of long- term graft failure.

Many researchers have analyzed the complex flow patterns in the distal sapheno-coronary anastomotic region, using various simulated model in an attempt to explain the site of preferential intimal hyperplasia based on the flow disturbances and differential wall stress distribution. In this paper, the geometrical bypass models (aorto-left coronary bypass graft model and aorto-right coronary bypass graft model) are based on real-life situations. In our models, the dimensions of the aorta, saphenous vein and the coronary artery simulate the actual dimensions at surgery. Both the proximal and distal anastomoses are considered at the same time, and we also take into the consideration the cross-sectional shape change of the venous conduit from circular to elliptical. Contrary to previous works, we have carried out computational fluid dynamics (CFD) study in the entire aorta-graft-perfused artery domain. The results reported here focus on (i) the complex flow patterns both at the proximal and distal anastomotic sites, and (ii) the wall shear stress distribution, which is an important factor that contributes to graft patency.

Methods

The three-dimensional coronary bypass models of the aorto-right coronary bypass and the aorto-left coronary bypass systems are constructed using computational fluid-dynamics software (Fluent 6.0.1). To have a better understanding of the flow dynamics at specific time instants of the cardiac cycle, quasi-steady flow simulations are performed, using a finite-volume approach. The data input to the models are the physiological measurements of flow-rates at (i) the aortic entrance, (ii) the ascending aorta, (iii) the left coronary artery, and (iv) the right coronary artery.

Results

The flow field and the wall shear stress are calculated throughout the cycle, but reported in this paper at two different instants of the cardiac cycle, one at the onset of ejection and the other during mid-diastole for both the right and left aorto-coronary bypass graft models. Plots of velocity-vector and the wall shear stress distributions are displayed in the aorto-graft-coronary arterial flow-field domain. We have shown (i) how the blocked coronary artery is being perfused in systole and diastole, (ii) the flow patterns at the two anastomotic junctions, proximal and distal anastomotic sites, and (iii) the shear stress distributions and their associations with arterial disease.

Conclusion

The computed results have revealed that (i) maximum perfusion of the occluded artery occurs during mid-diastole, and (ii) the maximum wall shear-stress variation is observed around the distal anastomotic region. These results can enable the clinicians to have a better understanding of vein graft disease, and hopefully we can offer a solution to alleviate or delay the occurrence of vein graft disease.

Particle hemodynamics analysis of Miller cuff arterial anastomosis

OBJECTIVE

Studies of animal and human below-knee anastomoses with Miller cuffs indicate that improved graft patency results from redistribution of intimal hyperplasia away from areas critical to flow delivery, such as the arterial toe. We hypothesize that particle hemodynamic conditions are a biophysical mechanism potentially responsible for the clinically observed shift in intimal hyperplasia localization associated with better patency of the Miller configuration.

METHODS

Computational fluid dynamics analysis of vortical flow patterns, wall shear stress fields, and potential for platelet interaction with the vascular surface was performed for realistic three-dimensional conventional and Miller cuff distal end-to-side anastomoses. Sites of significant platelet-wall interaction, including elevated near-wall particle concentrations and stasis, were identified with a validated near-wall residence time model, which includes shear stress-based factors for particle activation and surface reactivity.

RESULTS

Particle hemodynamics largely coincide with the observed redistribution of intimal hyperplasia away from the critical arterial toe region. Detrimental changes in wall shear stress vector magnitude and direction are significantly reduced along the arterial suture line of the Miller cuff, largely as a result of increased anastomotic area available for flow redirection. However, because of strong particle-wall interaction, resulting high near-wall residence time contours indicate significant intimal hyperplasia along the graft-vein suture line and in the vicinity of the arterial heel.

CONCLUSIONS

While a number of interacting mechanical, biophysical, and technical factors may be responsible for improved Miller cuff patency, our results imply that particle hemodynamics conditions engendered by Miller cuff geometry provide a mechanism that may account for redistribution of intimal hyperplasia. In particular, it appears that a focal region of significant particle-wall interaction at the arterial toe is substantially reduced with the Miller cuff configuration.

Particle-hemodynamics modeling of the distal end-to-side femoral bypass: effects of graft caliber and graft-end cut

Late-stage occlusions of peripheral synthetic bypass grafts are frequently due to intimal hyperplasia and/or thrombosis at the distal anastomosis, resulting in unacceptably high failure rates. It has been widely established that hemodynamic and blood particle interactions with the vascular surface as well as surgical injury and compliance mismatch are inciting mechanisms capable of eliciting various cellular level responses associated with distal anastomotic intimal hyperplasia (IH) formation. Primary geometric factors influencing anastomotic hemodynamics include the graft-to-artery diameter ratio and graft-hood shape, which are determined by the graft caliber and initial graft-end cut selected by the vascular surgeon. In this study, the particle-hemodynamic effects of graft-end cuts (straight, curved, and S-shaped) and graft-to-artery diameter ratios (2:1 vs. 1.5:1) have been numerically assessed in four common unexpanded anastomotic configurations with respect to vortical flow patterns, wall shear stress based parameters, and platelet interactions with the vascular surface. Sites of significant platelet-wall interactions have been identified by a novel near-wall residence time (NWRT) model, which includes shear stress based factors for platelet activation and endothelial cell expression of anti-thrombogenic compounds. Of the configurations evaluated, straight and curved graft-end cuts with a graft-to-artery diameter ratio of 1.5:1 were found to reduce the particle-hemodynamic potential for IH development at locations critical to flow delivery. Nevertheless, the potential for significant IH occurrence via platelet and/or endothelial response pathways was highly evident in all conventional anastomoses considered, such that a decisively superior configuration was not determined. These results illustrate the need for alternative anastomotic designs with the intent of reducing critical hemodynamic wall parameters and mitigating regions of significant particle-wall interactions.

Numerical Simulation of Wall Shear Stress Conditions and Platelet Localization in Realistic End-to-Side Arterial Anastomoses

Research studies over the last three decades have established that hemodynamic interactions with the vascular surface as well as surgical injury are inciting mechanisms capable of eliciting distal anastomotic intimal hyperplasia (IH) and ultimate bypass graft failure. While abnormal wall shear stress (WSS) conditions have been widely shown to affect vascular biology and arterial wall self-regulation, the near-wall localization of critical blood particles by convection and diffusion may also play a significant role in IH development. It is hypothesized that locations of elevated platelet interactions with reactive or activated vascular surfaces, due to injury or endothelial dysfunction, are highly susceptible to IH initialization and progression. In an effort to assess the potential role of platelet-wall interactions, experimentally validated particle-hemodynamic simulations have been conducted for two commonly implemented end-to-side anastomotic configurations, with and without proximal outflow. Specifically, sites of significant particle interactions with the vascular surface have been identified by a novel near-wall residence time (NWRT) model for platelets, which includes shear stress-based factors for platelet activation as well as endothelial cell expression of thrombogenic and anti-thrombogenic compounds. Results indicate that the composite NWRT model for platelet-wall interactions effectively captures a reported shift in significant IH formation from the arterial floor of a relatively high-angle (30 deg) graft with no proximal outflow to the graft hood of a low-angle graft (10 deg) with 20% proximal outflow. In contrast, other WSS-based hemodynamic parameters did not identify the observed system-dependent shift in IH formation. However, large variations in WSS-vector magnitude and direction, as encapsulated by the WSS-gradient and WSS-angle-gradient parameters, were consistently observed along the IH-prone suture-line region. Of the multiple hemodynamic factors capable of eliciting a hyperplastic response at the cellular level, results of this study indicate the potential significance of platelet-wall interactions coinciding with regions of low WSS in the development of IH.

Correlation of Intimal Hyperplasia Development and Shear Stress Distribution at the Distal End-side-anastomosis, in vitro Study Using Particle Image Velocimetry

Low shear areas at the distal anastomosis of peripheral bypasses are thought to promote neointimal hyperplasia. In this study we evaluated the fluid dynamic environment at the distal anastomosis of peripheral bypasses by means of a new method for in vitro flow visualization and quantitative velocity field measurement. A silastic model of a distal end-side anastomosis was attached to a mock circulation loop driven by an artificial heart. High resolution velocity fields were measured by means of particle image velocimetry (PIV). The velocity vector data were used to calculate vorticity omega, strain rates ex, shear rates h and shear stresses tau. Two separations and a stagnation zone were identified by means of flow visualization. Measured velocities inside the three zones were significantly lower than in the high velocity mainstream. Calculated shear rates and shear stresses inside the zones were significantly lower than human wall shear rates. At the transition between the effective mainstream and the boundary layers high vorticity and compressive strain fields existed, indicating the presence of high shear forces. The locations of these areas corresponded to the well known zones of intimal hyperplasia. The high resolution shear stress analysis supports the low shear theory of intimal hyperplasia development. A wall diversion angle greater than 6 degrees leads to flow separation and presumed IH promotion until high shear transition areas are reached.

Prevalence and treatment of cephalic arch stenosis in dysfunctional autogenous hemodialysis fistulas

PURPOSE

Cephalic arch stenosis (CAS) is a recently recognized cause of dysfunction in autogenous hemodialysis fistulas. The prevalence of this lesion among dysfunctional autogenous fistulas is described, as are outcomes after percutaneous therapy.

MATERIALS AND METHODS

A cohort of 177 dysfunctional autogenous fistulas treated over a 48-month period was retrospectively analyzed for the presence of CAS. Of these, 116 (66%) were radiocephalic fistulas and 61 (34%) were brachiocephalic fistulas. CAS was identified in 26 fistulas among 24 patients. Fifty dilations and three stent placements in the cephalic arch were performed. Surveillance was conducted after percutaneous therapy by means of ultrasound dilution technique and measurement of dialysis flow rates. Patency rates were estimated with use of the Kaplan-Meier method. No patients were lost to follow-up.

RESULTS

The prevalence of CAS was 15% (26 of 177). There was a significant difference in the prevalence of CAS between brachiocephalic and radiocephalic fistulas (39% vs 2%; P <.001). High-pressure noncompliant balloon catheters were required in 29 of 50 dilations (58%) to efface the lesion. Primary patency rates (+/-SE) at 3, 6, and 12 months were 76% +/- 8, 42% +/- 10, and 23% +/- 9, respectively. Primary assisted patency rates (+/-SE) at 3, 6, and 12 months were 96% +/- 4, 83% +/- 8, and 75% +/- 10. Complications occurred in three cases (6%). A major complication with rupture of the cephalic arch resulted in thrombosis and fistula loss (n = 1); two minor complications of cephalic arch rupture were salvaged with placement of a Wallstent (n = 1) or prolonged balloon inflation (n = 1).

CONCLUSIONS

CAS is common among failing brachiocephalic arteriovenous fistulas. With aggressive percutaneous intervention and surveillance, favorable primary assisted patency rates can be achieved.

Transitional flow at the venous anastomosis of an arteriovenous graft: potential activation of the ERK1/2 mechanotransduction pathway

We present experimental and computational results that describe the level, distribution, and importance of velocity fluctuations within the venous anastomosis of an arteriovenous graft. The motivation of this work is to understand better the importance of biomechanical forces in the development of intimal hyperplasia within these grafts. Steady-flow in vitro studies (Re = 1060 and 1820) were conducted within a graft model that represents the venous anastomosis to measure velocity by means of laser Doppler anemometry. Numerical simulations with the same geometry and flow conditions were conducted by employing the spectral element technique. As flow enters the vein from the graft, the velocity field exhibits flow separation and coherent structures (weak turbulence) that originate from the separation shear layer. We also report results of a porcine animal study in which the distribution and magnitude of vein-wall vibration on the venous anastomosis were measured at the time of graft construction. Preliminary molecular biology studies indicate elevated activity levels of the extracellular regulatory kinase ERK1/2, a mitogen-activated protein kinase involved in mechanotransduction, at regions of increased vein-wall vibration. These findings suggest a potential relationship between the associated turbulence-induced vein-wall vibration and the development of intimal hyperplasia in arteriovenous grafts. Further research is necessary, however, in order to determine if a correlation exists and to differentiate the vibration effect from that of flow related effects.

The influence of out-of-plane geometry on pulsatile flow within a distal end-to-side anastomosis

We present an experimental and computational investigation of time-varying flow in an idealized fully occluded 45 degrees distal end-to-side anastomosis. Two geometric configurations are assessed, one where the centerlines of host and bypass vessels lie within a plane, and one where the bypass vessel is deformed out of the plane of symmetry, respectively, termed planar and non-planar. Flow experiments were conducted by magnetic resonance imaging in rigid wall models and computations were performed using a high order spectral/hp algorithm. Results indicate a significant change in the spatial distribution of wall shear stress and a reduction of the time-averaged peak wall shear stress magnitude by 10% in the non-planar model as compared to the planar configuration. In the planar geometry the stagnation point follows a straight-line path along the host artery bed with a path length of 0.8 diameters. By contrast in the non-planar case the stagnation point oscillates about a center that is located off the symmetry plane intersection with the host artery bed wall, and follows a parabolic path with a 0.7 diameter longitudinal and 0.5 diameter transverse excursion. A definition of the oscillatory shear index (OSI) is introduced that varies between 0 and 0.5 and that accounts for a continuous range of wall shear stress vector angles. In both models, regions of elevated oscillatory shear were spatially associated with regions of separated or oscillating stagnation point flow. The mean oscillatory shear magnitude (considering sites where OSI>0.1) in the non-planar geometry was reduced by 22% as compared to the planar configuration. These changes in the dynamic behavior of the stagnation point and the oscillatory shear distribution introduced by out-of-plane graft curvature may influence the localization of vessel wall sites exposed to physiologically unfavorable flow conditions.

Relative contribution of wall shear stress and injury in experimental intimal thickening at PTFE end-to-side arterial anastomoses

BACKGROUND

Intimal hyperplastic thickening (IHT) is a frequent cause of prosthetic bypass graft failure. Induction and progression of IHT is thought to involve a number of mechanisms related to variation in the flow field, injury and the prosthetic nature of the conduit. This study was designed to examine the relative contribution of wall shear stress and injury to the induction of IHT at defined regions of experimental end-to-side prosthetic anastomoses.

METHODS AND RESULTS

The distribution of IHT was determined at the distal end-to-side anastomosis of seven canine Iliofemoral PTFE grafts after 12 weeks of implantation. An upscaled transparent model was constructed using the in vivo anastomotic geometry, and wall shear stress was determined at 24 axial locations from laser Doppler anemometry measurements of the near wall velocity under conditions of pulsatile flow similar to that present in vivo. The distribution of IHT at the end-to-side PTFE graft was determined using computer assisted morphometry. IHT involving the native artery ranged from 0.0+/-0.1 mm to 0.05+/-0.03 mm. A greater amount of IHT was found on the graft hood (PTFE) and ranged from 0.09+/-0.06 to 0.24+/-0.06 mm. Nonlinear multivariable logistic analysis was used to model IHT as a function of the reciprocal of wall shear stress, distance from the suture line, and vascular conduit type (i.e. PTFE versus host artery). Vascular conduit type and distance from the suture line independently contributed to IHT. An inverse correlation between wall shear stress and IHT was found only for those regions located on the juxta-anastomotic PTFE graft.

CONCLUSIONS

The data are consistent with a model of intimal thickening in which the intimal hyperplastic pannus migrating from the suture line was enhanced by reduced levels of wall shear stress at the PTFE graft/host artery interface. Such hemodynamic modulation of injury induced IHT was absent at the neighboring artery wall.

Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas

PURPOSE

To assess patency after percutaneous treatment of dysfunctional and thrombosed native arteriovenous fistulas and to examine predictors of patency after intervention.

MATERIALS AND METHODS

A cohort of 65 consecutive patients with dysfunctional (n = 53) or occluded (n = 12) native fistulas who underwent 96 percutaneous interventions over an 18-month period was retrospectively analyzed. Fistula locations were radiocephalic (n = 37), brachiocephalic (n = 10), or brachiobasilic (n = 18). Primary interventions consisted of angioplasty (n = 50), stent placement (n = 3), or percutaneous thrombolysis/thrombectomy (n = 12). Additional interventions during follow-up consisted of angioplasty (n = 22), stent placement (n = 6), or percutaneous thrombolysis/thrombectomy (n = 3). Duration of fistula function was assessed clinically and examined as a function of anatomic and clinical variables with use of Cox hazards models and the Kaplan-Meier method.

RESULTS

Clinical success with resumption of at least one session of normal dialysis occurred in 94% (90 of 96) of interventions. The 30-day morbidity rate was 2.1%; no procedure-related deaths occurred. Primary, assisted primary, and secondary patency rates (+/- SE) of dysfunctional fistulas after intervention at 12 months were 26% +/- 11%, 80% +/- 6%, and 82% +/- 6%. Occluded fistulas after intervention had 3-month primary, assisted primary, and secondary patency rates of 60% +/- 15%, 60% +/- 15%, and 80% +/- 13%. Lesions 2.0 cm or more in length were five times more likely to have loss of patency than lesions smaller than 2.0 cm. The presence of at least one comorbid factor--diabetes, coronary artery disease, or peripheral vascular disease--was associated with nearly twice the risk of patency loss after any intervention.

CONCLUSION

Despite modest primary patency rates in our experience, high assisted and secondary patency rates can be achieved with percutaneous intervention in native arteriovenous fistulas. These findings emphasize the need for close surveillance of native fistulas and a low threshold for diagnostic fistulography after initial intervention. The most detrimental determinant of outcome was lesion length > or =2 cm.

Assessing the accuracy of two-dimensional phase-contrast MRI measurements of complex unsteady flows

Two-dimensional phase-contrast MRI measurements of complex unsteady flows have been assessed for accuracy, together with procedures used to improve the precision of the measurements. Velocity measurements of single harmonic sinusoidal flow in a rigid bypass graft model with a fully three-dimensional geometry were compared to an accurate numerical solution of the Navier-Stokes equations for the same flow. Axial velocity profiles from the MRI were compared with the computational data, and instantaneous root mean square (rms) differences were calculated. Despite the complexity of the flow, with the aid of phase angle dynamic range extension, a spatially and temporally averaged rms error of between 7.8% and 11.5%, with respect to the spatially and temporally averaged velocity, was achieved. Spin saturation primarily and phase dispersion secondarily in complex transient recirculation zones were found to be significant contributors to overall error. Cross flow effects were also investigated but were of lesser significance. The result confirms the suitability of the technique for measuring complex unsteady flows.

A numerical simulation of steady flow fields in a bypass tube

Steady flow in a complete by-pass tube was simulated numerically. The study was to consider a complete flow field, which included both the by-pass and the host tubes. The changes of the hemodynamics were investigated with three parameters: the inlet flow Reynolds number (Re), anastomotic angle (alpha) and the position of the occlusion in the host tube. The baseline flow field was set up with Re=200, alpha=45 degrees and the centered position of occlusion. The parametric study was then conducted on combination of Re=100, 200, 400, alpha=35 degrees, 45 degrees, 60 degrees, 75 degrees, 90 degrees and three occlusion positions: left, center and right. It was found that in the baseline case, large slow/recirculation flows could be seen in the host tube both upstream and downstream of the occlusion. The separation points were on the opposite walls to the junctions. Recirculation zones were also found near the toe and in the proximal outer wall of the by-pass tube. Their sizes were about one diameter of the tube or smaller. In some cases, pairing vortices could be seen in the host tube upstream of the occlusion. The shear rate distribution associated with the flow fields was presented. The flow pattern obtained was agreeable to those observed experimentally by other investigators. The difference of the flow fields between a complete bypass and simple anastomosis was discussed. The present numerical code provides a preliminary simulation/design tool for bypass graft flows.

The effect of proximal artery flow on the hemodynamics at the distal anastomosis of a vascular bypass graft: computational study

The formation of distal anastomotic intimal hyperplasia (IH), one common mode of bypass graft failure, has been shown to occur in the areas of disturbed flow particular to this site. The nature of theflow in the segment of artery proximal to the distal anastomosis varies from case to case depending on the clinical situation presented. A partial stenosis of a bypassed arterial segment may allow residual prograde flow through the proximal artery entering the distal anastomosis of the graft. A complete stenosis may allow for zero flow in the proximal artery segment or retrograde flow due to the presence of small collateral vessels upstream. Although a number of investigations on the hemodynamics at the distal anastomosis of an end-to-side bypass graft have been conducted, there has not been a uniform treatment of the proximal artery flow condition. As a result, direct comparison of results from study to study may not be appropriate. The purpose of this work was to perform a three-dimensional computational investigation to study the effect of the proximal artery flow condition (i.e., prograde, zero, and retrograde flow) on the hemodynamics at the distal end-to-side anastomosis. We used the finite volume method to solve the full Navier-Stokes equations for steady flow through an idealized geometry of the distal anastomosis. We calculated the flow field and local wall shear stress (WSS) and WSS gradient (WSSG) everywhere in the domain. We also calculated the severity parameter (SP), a quantification of hemodynamic variation, at the anastomosis. Our model showed a marked difference in both the magnitude and spatial distribution of WSS and WSSG. For example, the maximum WSS magnitude on the floor of the artery proximal to the anastomosis for the prograde and zero flow cases is 1.8 and 3.9 dynes/cm2, respectively, while it is increased to 10.3 dynes/cm2 in the retrograde flow case. Similarly, the maximum value of WSSG magnitude on thefloor of the artery proximal to the anastomosis for the prograde flow case is 4.9 dynes/cm3, while it is increased to 13.6 and 24.2 dynes/cm3, respectively, in the zero and retrograde flow cases. The value of SP is highest for the retrograde flow case (13.7 dynes/cm3) and 8.1 and 12.1 percent lower than this for the prograde (12.6 dynes/cm3) and zero (12.0 dynes/cm3) flow cases, respectively. Our model results suggest that the flow condition in the proximal artery is an important determinant of the hemodynamics at the distal anastomosis of end-to-side vascular bypass grafts. Because hemodynamic forces affect the response of vascular endothelial cells, the flow situation in the proximal artery may affect IH formation and, therefore, long-term graft patency. Since surgeons have some control over the flow condition in the proximal artery, results from this study could help determine which flow condition is clinically optimal.

Local haemodynamics of arterial bypass graft anastomoses

One of the main causes of failure of expanded polytetrafluoroethylene (PTFE) bypass grafts used in the lower limbs is the development of myointimal hyperplasia (MIH). Clinical studies show that higher patency rates can be obtained with the use of an autologous vein cuff (the Miller cuff) interposed between the graft and artery. The reasons for the improved performance are still unclear, but preliminary studies suggest that the change in local haemodynamics due to the cuff geometry may be the significant factor rather than the presence of autologous material. If this is the case, then PTFE grafts can be produced with an integral cuff, i.e. a precuffed graft, with similar haemodynamic patterns to that of the Miller cuff. In this paper, two different types of precuffed graft are presented and their flow patterns are compared with those recorded in the Miller cuff and the conventional end-to-side anastomosis. The haemodynamic studies were carried out using optically clear silicone rubber models under simulated in vivo pulsatile flow conditions. Flow structures similar to those observed in the Miller cuff were seen in the precuffed grafts.

Blood flow in distal end-to-side anastomoses with PTFE and a venous patch: results of an in vitro flow visualisation study

OBJECTIVES

non-physiological flow behaviour plays a significant role in the development of distal anastomotic intimal hyperplasia. To investigate flow patterns in four anastomotic types of femoral end-to-side distal bypass graft anastomoses, a flow visualisation study was performed.

METHODS

transparent 1:1 casted replicas of distal vascular graft anastomoses created by conventional technique, Miller-cuff, Taylor- and Linton-patch were fabricated. A pulsatile mock circulation with a high-speed video system was constructed. Flow pattern was determined at mean Reynolds numbers 100-500. Migrations of the stagnation points on the bottom of the anastomoses at mean Reynolds numbers 100, 230, and 350 were measured.

RESULTS

a vortex forms during early systole and increases to maximum systole in all anastomoses. During the diastolic phase the vortex moves in the Miller-cuff distally to the toe of the anastomosis and remains standing, while in the other anastomotic types the vortex moves proximally to the heal of the junction and breaks down. The shift of the stagnation point in the Miller-cuff was considerably smaller than in the other anastomoses.

CONCLUSION

conventional, Linton and Taylor anastomoses show similar flow patterns. The Miller-cuff with its wider cavity shows lower shift of the bottom stagnation point, but a persistent washout of the anastomotic cavity, which may contribute to its reported good clinical performance.

Velocity and wall shear stress patterns in the human right coronary artery

Blood flow dynamics in the human right coronary artery have not been adequately quantified despite the clinical significance of coronary atherosclerosis. In this study, a technique was developed to construct a rigid flow model from a cast of a human right coronary artery. A laser photochromic method was used to characterize the velocity and wall shear stress patterns. The flow conditions include steady flow at Reynolds numbers of 500 and 1000 as well as unsteady flow with Womersley parameter and peak Reynolds number of 1.82 and 750, respectively. Characterization of the three-dimensional geometry of the artery revealed that the largest spatial variation in curvature occurred within the almost branch-free proximal region, with the greatest curvature existing along the acute margin of the heart. In the proximal segment, high shear stresses were observed on the outer wall and lower, but not negative, stresses along the inner wall. Low shear stress on the inner wall may be related to the preferential localization of atherosclerosis in the proximal segment of the right coronary artery. However, it is possible that the large difference between the outer and inner wall shear stresses may also be involved.

The effect of graft caliber upon wall shear within in vivo distal vascular anastomoses

Wall shear has been widely implicated as a contributing factor in the development of intimal hyperplasia in the anastomoses of chronic arterial bypass grafts. Earlier studies have been restricted to either: (1) in vitro or computer simulation models detailing the complex hemodynamics within an anastomosis without corresponding biological responses, or (2) in vivo models that document biological effects with only approximate wall shear information. Recently, a specially designed pulse ultrasonic Doppler wall shear rate (PUDWSR) measuring device has made it possible to obtain three near-wall velocity measurements nonintrusively within 1.05 mm of the vessel luminal surface from which wall shear rates (WSRs) were derived. It was the purpose of this study to evaluate the effect of graft caliber, a surgically controllable variable, upon local hemodynamics, which, in turn, play an important role in the eventual development of anastomotic hyperplasia. Tapered (4-7 mm I.D.) 6-cm-long grafts were implanted bilaterally in an end-to-side fashion with 30 deg proximal and distal anastomoses to bypass occluded common carotid arteries of 16 canines. The bypass grafts were randomly paired in contralateral vessels and placed such that the graft-to-artery diameter ratio, DR, at the distal anastomosis was either 1.0 or 1.5. For all grafts, the average Re was 432 +/- 112 and the average Womersley parameter, alpha, was 3.59 +/- 0.39 based on artery diameter. There was a sharp skewing of flow toward the artery floor with the development of a stagnation point whose position varied with time (up to two artery diameters) and DR (generally more downstream for DR = 1.0). Mean WSRs along the artery floor for DR = 1.0 and 1.5 were found to range sharply from moderate to high retrograde values (589 s-1 and 1558 s-1, respectively) upstream to high antegrade values (2704 s-1 and 2302 s-1, respectively) immediately downstream of the stagnation point. Although there were no overall differences in mean and peak WSRs between groups, there were significant differences (p < 0.05) in oscillatory WSRs as well as in the absolute normalized mean and peak WSRs between groups. There were also significant differences (p < 0.05) in mean and peak WSRs with respect to axial position along the artery floor for both DR cases. In conclusion, WSR varies widely (1558 s-1 retrograde to 2704 s-1 antegrade) within end-to-side distal graft anastomoses, particularly along the artery floor, and may play a role in the development of intimal hyperplasia through local alteration of mass transport and mechano-signal transduction within the endothelium.

Compliance mismatch may promote graft-artery intimal hyperplasia by altering suture-line stresses

The role of graft-artery compliance mismatch in the development of distal anastomotic intimal hyperplasia (DAIH) is not yet resolved. Although DAIH develops at all surgically created anastomoses, increased compliance mismatch does not lead to greater hyperplasia formation in end-to-end anastomoses, but in end-to-side anastomoses, it leads to a profound increase in hyperplasia. The current study was undertaken to determine whether suture-induced anastomotic stresses could explain these findings. A large strain finite element analysis of vascular wall mechanics was performed to compare the influence of compliance mismatch on intramural stresses in end-to-end versus end-to-side anastomoses. A novel modelling approach was implemented which includes suture-induced stress concentrations. End-to-end and end-to-side graft-artery simulations were executed using (1) artery (compliance = C = 0.44% kPa(-1)), (2) vein (C = 0.33% kPa(-1)), and (3) Dacron (C = 0.14% kPa(-1)) grafts. Residual stresses due to axial tension were included and the anastomoses were statically inflated to 13.3 kPa (100 mmHg). Elevated intramural stresses were found to exist at both the end-to-end and end-to-side graft-artery junctions; however, in the end-to-end anastomosis, the maximum anastomotic stress was not a function of the graft compliance, whereas in the end-to-side anastomosis, the maximum stress was a strong function of graft compliance. For the 45 degree end-to-side geometry considered in this study, the maximum anastomotic stress concentration obtained using a stiff Dacron graft was more than 40% greater than that obtained using a compliant artery graft. In the end-to-end anastomosis, the Dacron graft led to a less than 5% increase in maximum stress over the artery graft. Therefore, increased compliance mismatch increases stresses and promotes DAIH in end-to-side junctions, but, it has little influence on either stresses or DAIH in end-to-end junctions. Thus, the proliferative influence of increased compliance mismatch on suture-line hyperplasia in end-to-side anastomoses can be explained by the resulting increase in intramural stresses. In addition, since high stresses were found in both geometries, elevated suture-line intramural stresses may be an important proliferative stimulus for intimal hyperplasia formation in all vascular reconstructions.

Measurements of velocity and wall shear stress inside a PTFE vascular graft model under steady flow conditions

The flow field inside a model of a polytetrafluorethylene (PTFE) canine artery end-to-side bypass graft was studied under steady flow conditions using laser-Doppler anemometry. The anatomically realistic in vitro model was constructed to incorporate the major geometric features of the in vivo canine anastomosis geometry, most notably a larger graft than host artery diameter. The velocity measurements at Reynolds number 208, based on the host artery diameter, show the flow field to be three dimensional in nature. The wall shear stress distribution, computed from the near-wall velocity gradients, reveals a relatively low wall shear stress region on the wall opposite to the graft near the stagnation point approximately one artery diameter in axial length at the midplane. This low wall shear stress region extends to the sidewalls, suture lines, and along the PTFE graft where its axial length at the midplane is more than two artery diameters. The velocity distribution inside the graft model presented here provides a data set well suited for validation of numerical solutions on a model of this type.

In-vivo measurements of blood flow velocity profiles in canine ilio-femoral anastomotic bypass grafts

In-vivo velocity profiles were recorded with a 20 MHz 80-channel pulsed Doppler ultrasound velocimeter in canine end-to-side ilio-femoral anastomotic grafts. The geometries were obtained from casts of the anastomotic region, and flow rates were measured with electromagnetic flow probes. Three cases reported here include a "standard" geometry, which was similar to previously studied in vitro models, a stenosed geometry, and a case with below average flow rate. Observed flow features include separation at the hood and toe, movement of the floor stagnation point, and skewed profiles in the proximal outflow segment. Out-of-plane curvature and lateral displacement of the anastomosis inlet appear to have a strong effect on the flow fields. In addition, compliance affects the instantaneous flow rates within the proximal and distal branches.

Effects of geometry and flow division on flow structures in models of the distal end-to-side anastomosis

Flow structures in models of the distal end-to-side anastomosis were visualised under steady and pulsatile flow conditions using planar illumination of suspended tracer particles. The effects of anastomosis geometry and flow in the proximal artery were investigated in models with anastomosis angles of 15, 30 or 45 degrees. The flow patterns in steady flow were highly three-dimensional and comprised two helical vortices in the distal artery, a recirculation vortex in the occluded proximal arterial segment and a stagnation point on the floor of the artery. Flow separation was observed at the toe of the anastomosis in the 30 and 45 degree models only. A second separation point was also found on the near wall of the 30 degree models at higher flow rates. Downstream flow in the proximal artery reduced and even eliminated the flow recirculation at the heel of the anastomosis, while upstream flow resulted in a captive vortex at the heel and flow reversal at the toe. In pulsatile flow, the secondary flow components in the distal artery became more pronounced during flow deceleration, particularly at higher Reynolds numbers. Significant flow reversal was observed at the toe of the anastomosis and this extended several vessel diameters along the near wall of the artery and upstream into the hood of the graft. The floor of the artery was subjected to a continually varying shear rate caused by the movement of the stagnation point during the pulsatile cycle. The results are in agreement with the observation that intimal hyperplasia occurs in regions of flow separation at the toe and the heel, and flow stagnation on the floor of the anastomosis.

Numerical analysis of steady flow in aorto-coronary bypass 3-D model

Intimal hyperplasia and atherosclerosis have a predominant role in the failure of coronary artery bypass procedures. Theoretical studies and in vivo observations have shown that these pathologies are much more likely to occur in the proximity of end-to-side anastomosis, thus indicating that fluid dynamic conditions may be included in the pathogenic causes of the initiation, progression and complication of intimal hyperplasia. In order to study the fluid dynamics at the anastomosis of an aortocoronary bypass, a three-dimensional mathematical model based on a FEM approach was developed. Steady-state simulations were studied in two different geometrical models of anastomosis which differ in their insertion angles (45 and 60 degree). Flow fields with three-dimensional helical patterns, secondary flows, and shear stresses were also investigated. The results show the presence of low shear stresses on the top wall just beyond the toe of the anastomosis and in the region of the coronary artery before the junction. A high wall shear stress region is present on the lateral wall of the coronary artery immediately downstream from the anastomosis. The influence of flow rate distribution on the secondary flows is also illustrated. These results confirm the sensitivity of flow behavior to the model's geometrical parameters and enhance the importance of reproducing the anastomosis junction as closely as possible in order to evaluate the effective shear stress distribution.

Flow visualization with air and smoke in a bypass graft model under steady flow conditions

A new technique for visualizing the steady flow of a new type of test fluid is presented that produces quality photographic results at Reynolds numbers typically found in arterial bypass grafts. Room air functions as the test fluid and smoke from burning incense sticks provides the tracer particles. As an example of this new technique, photographic results are presented for a Reynolds number flow of 205 through a Plexiglas model of an end-to-side distal anastomosis with a 45 degrees junction angle. The advantages of this technique are that it is simple, convenient, and applicable to a wide variety of flow conditions found in the human cardiovascular system.