Tibial Artery Stent Deformations From Ankle Plantarflexion and Dorsiflexion, Knee Flexion, and Simulated Calf Muscle Contraction

Background

Tibial artery stent deformations have not been previously published and are critical for the evaluation and development of below-the-knee treatments.

Methods

Balloon-expandable stents were implanted into the anterior tibial, posterior tibial, and peroneal arteries of cadaver legs, including ostium-crossing locations. Computed tomography and geometric modeling were used to quantify cross-sectional, axial, and bending stent deformations from ankle plantarflexion/dorsiflexion, knee flexion, and simulated calf muscle contraction for walking/running.

Results

Single and overlapping stents (N = 53) were deployed into 23 tibial arteries and across 6 ostia. Diametric crush was experienced in the posterior tibial with knee flexion (-5.3% ± 3.2%, P < .0001) and peroneal with ankle dorsiflexion (-2.4% ± 2.0%, P = .0016), and posterior tibial stents experienced greater diametric crush from knee flexion (-5.3% ± 3.2%) and calf compression (-3.4% ± 5.9%) compared to ankle motion (-0.2% ± 4.3%; P = .0009 and P = .0061, respectively). Ostium-crossing stents experienced order of magnitude higher axial shortening with knee flexion and ankle plantarflexion compared to those in single arteries. No stent bending was observed from any leg motion.

Conclusions

Diametric crush in posterior tibial and peroneal stents was potentially due to their location in the deep posterior compartment and adjacent to the soleus/gastrocnemius muscles that bulge with joint motion. Crush in the posterior tibial is greater for knee flexion and calf compression compared to ankle motion from a higher bone-to-muscle ratio near the ankle protecting against crush. Ostium-crossing stents experience larger shortening than those in individual arteries potentially because of a more oblique orientation. No significant stent bending was observed possibly because the midcalf is distant from knee and ankle joints and protected by the rigid tibia and fibula. These stent deformations can guide device development, interventional site selection, and indications for use.

Ascending Aortic Endograft and Thoracic Aortic Deformation After Ascending Thoracic Endovascular Aortic Repair

PURPOSE

We aim to quantify multiaxial cardiac pulsatility-induced deformation of the thoracic aorta after ascending thoracic endovascular aortic repair (TEVAR) as a part of the GORE ARISE Early Feasibility Study.

MATERIALS AND METHODS

Fifteen patients (7 females and 8 males, age 73±9 years) with ascending TEVAR underwent computed tomography angiography with retrospective cardiac gating. Geometric modeling of the thoracic aorta was performed; geometric features including axial length, effective diameter, and centerline, inner surface, and outer surface curvatures were quantified for systole and diastole; and pulsatile deformations were calculated for the ascending aorta, arch, and descending aorta.

RESULTS

From diastole to systole, the ascending endograft exhibited straightening of the centerline (0.224±0.039 to 0.217±0.039 cm-1, p<0.05) and outer surface (0.181±0.028 to 0.177±0.029 cm-1, p<0.05) curvatures. No significant changes were observed for inner surface curvature, diameter, or axial length in the ascending endograft. The aortic arch did not exhibit any significant deformation in axial length, diameter, or curvature. The descending aorta exhibited small but significant expansion of effective diameter from 2.59±0.46 to 2.63±0.44 cm (p<0.05).

CONCLUSION

Compared with the native ascending aorta (from prior literature), ascending TEVAR damps axial and bending pulsatile deformations of the ascending aorta similar to how descending TEVAR damps descending aortic deformations, while diametric deformations are damped to a greater extent. Downstream diametric and bending pulsatility of the native descending aorta was muted compared with that in patients without ascending TEVAR (from prior literature). Deformation data from this study can be used to evaluate the mechanical durability of ascending aortic devices and inform physicians about the downstream effects of ascending TEVAR to help predict remodeling and guide future interventional strategies.

CLINICAL IMPACT

This study quantified local deformations of both stented ascending and native descending aortas to reveal the biomechanical impact of ascending TEVAR on the entire thoracic aorta, and reported that the ascending TEVAR muted cardiac-induced deformation of the stented ascending aorta and native descending aorta. Understanding of in vivo deformations of the stented ascending aorta, aortic arch and descending aorta can inform physicians about the downstream effects of ascending TEVAR. Notable reduction of compliance may lead to cardiac remodeling and long-term systemic complications. This is the first report which included dedicated deformation data regarding ascending aortic endograft from clinical trial.

Impact of Stenting on PDA Length, Curvature, and Pulsatile Deformations Based on CT Assessment

Background

We sought to investigate the impact of stenting on native patent ductus arteriosus (PDA) length, curvature, and pulsatile deformations in patients with ductal-dependent pulmonary circulations.

Methods

Patients with PDA stents who received contrast-enhanced 3-dimensional computed tomography with a view of the PDA, thoracic aorta, and pulmonary arteries were retrospectively included in this study. Geometric models of the prestented and poststented PDA were constructed from the computed tomography images, and PDA arclength, curvature, and pulsatile deformations were quantified.

Results

A total of 12 patients with cyanotic congenital heart disease were included, 10 of whom received 1 stent in the PDA and 2 received multiple overlapping stents. From prestenting to poststenting, the PDA shortened by 26 ± 18% (P = .004) and decreased in mean and peak curvature by 60 ± 21% and 68 ± 15%, respectively (both P < .001). Pulsatile deformations varied highly for the native PDA, stented PDA, and stents themselves.

Conclusions

The shortening and straightening of the PDA after stenting are significant and substantial, and their quantitative characterization will enable interventionalists to select stent lengths that span the entire PDA without encroaching on the aortic or pulmonary artery, which could cause hemodynamic interference, stent kink, and fatigue. Pulsatile PDA deformations can be used to design and evaluate devices tailored to congenital heart disease in neonates.

Stent deformations in the common iliac and iliofemoral veins as a result of hip flexion and extension

OBJECTIVE

In the present study, we characterized deformations of venous stents implanted into common iliac veins for nonthrombotic iliac vein lesions and iliofemoral veins for deep vein thrombosis due to hip movements commensurate with everyday activities such as walking, sitting, and stair climbing.

METHODS

Patients treated with iliofemoral venous stents were recruited from three centers and underwent imaging with two orthogonal two-dimensional projection radiographs. Stents in the common iliac veins and iliofemoral veins crossing the hip joint were imaged with the hip in 0°, 30°, 90° and -15°, 0°, and 30° positions, respectively. Using the radiographs, the three-dimensional geometries of the stents were constructed for each hip position, and the diametric and bending deformations between those positions were quantified.

RESULTS

Twelve patients were included, and the findings showed that the common iliac vein stents experienced approximately twofold more local diametric compression with 90° hip flexion compared with 30° flexion. Also, iliofemoral vein stents crossing the hip joint experienced significant bending with hip hyperextension (-15°) but not with hip flexion. In both anatomic locations, maximum local diametric and bending deformations were in proximity with each other.

CONCLUSIONS

Stents implanted in the common iliac and iliofemoral veins exhibit greater deformation during high hip flexion and hyperextension, respectively, and iliofemoral venous stents interact with the superior ramus of the pubis during hyperextension. These findings suggest that device fatigue could be influenced by the type and level of patient physical activity, in addition to anatomic positioning, opening up the potential benefit of activity modification and the use of a careful implantation strategy. The proximity of maximum diametric and bending deformations means that simultaneous multimodal deformations should be considered for device design and evaluation.

Pulsatile Deformations of a Conformable Descending Thoracic Aortic Endograft in Aneurysm, Dissection, and Blunt Traumatic Aortic Injury Patients

PURPOSE

This study presents analytic techniques to quantify cardiac pulsatility-induced deformations of thoracic aortic endografts in patients with thoracic aortic aneurysm (TAA), dissection (TAD), and blunt thoracic aortic injury (BTAI) after thoracic endovascular aortic repair (TEVAR).

TECHNIQUE

We analyzed 19 image data sets from 14 patients treated for TAA, TAD, and BTAI with cardiac-gated post-TEVAR CTs. Systolic and diastolic geometric models were constructed and diametric, axial, and bending deformations were quantified. For patients with cardiac-gated pre-op scans, the damping of pulsatile diametric distension was computed. Maximum localized diametric distension was 2.4±1.0%, 4.2±1.7%, and 5.5±1.6%, and axial deformation was 0.0±0.1%, -0.1±0.3%, and 1.1±0.6% in the endografts of TAA, TAD, and BTAI cohorts, respectively. Diametric distension damping from pre- to post-TEVAR was ~50%. Diametric and bending deformations were localized at certain axial positions on the endograft, and the inner curve bends more than the centerline, especially adjacent to overlapping regions.

CONCLUSION

The presented techniques support investigation of multi-axial endograft deformations between disease causes and geometric locations on the device. Discretized quantification of deformation is needed to define device fatigue testing conditions and predict device durability in patients.

CLINICAL IMPACT

This study demonstrates analytic techniques to quantify discretized deformation of thoracic endografts. Cardiac-resolved computed tomography is sometimes acquired for surgical planning and follow-up, however, the dynamic data are not typically used to quantify pulsatile deformations. Our analytic techniques extract the centerline and surface geometry of the stented thoracic aorta during the cardiac cycle, which are used to quantify diametric, axial, and bending deformations to provide better understanding of device durability and impact on the native anatomy.

Endothelial Cells Morphology in Response to Combined WSS and Biaxial CS: Introduction of Effective Strain Ratio

Introduction

Endothelial cells (ECs) morphology strongly depends on the imposed mechanical stimuli. These mechanical stimuli include wall shear stress (WSS) and biaxial cyclic stretches (CS). Under combined loading, the effect of CS is not as simple as pure CS. The present study investigates the morphological response of ECs to the realistic mechanical stimuli.

Methods

The cell population is theoretically studied using our previous validated model. The mechanical stimuli on ECs are described using four parameters; WSS magnitude (0 to 2.0 Pa), WSS angle (- 50° to 50°), and biaxial CS in two perpendicular directions (0 to 10%). The morphology of ECs is reported using four parameters; average shape index (SI) and orientation angle (OA) of the cell population as well as the standard deviation (SD) of SI and OA as measures for scattering of cells' SI and OA from these average values.

Results

A new effective strain ratio (ESR) is defined as the ratio of the undesirable CS to the desirable one. The obtained results of the model, illustrated that the SI and OA of cells increase with absolute value of ESR. In addition, the scattering in the SI of cells decreases with the absolute value of ESR, which means that the cell shapes become more regular. It is shown that the angular irregularity of cells increases at higher ESR values.

Conclusions

The results indicated that, the defined ESR is a stand-alone parameter for describing the realistic mechanical loading on the ECs and their morphological response.

Multimodal Loading Environment Predicts Bioresorbable Vascular Scaffolds' Durability

Bioresorbable vascular scaffolds were considered the fourth generation of endovascular implants deemed to revolutionize cardiovascular interventions. Yet, unexpected high risk of scaffold thrombosis and post-procedural myocardial infractions quenched the early enthusiasm and highlighted the gap between benchtop predictions and clinical observations. To better understand scaffold behavior in the mechanical environment of vessels, animal, and benchtop tests with multimodal loading environment were conducted using industrial standard scaffolds. Finite element analysis was also performed to study the relationship among structural failure, scaffold design, and load types. We identified that applying the combination of bending, axial compression, and torsion better reflects incidence observed in-vivo, far more than tranditional single mode loads. Predication of fracture locations is also more accurate when at least bending and axial compression are applied during benchtop tests (>60% fractures at connected peak). These structural failures may be initiated by implantation-induced microstructural damages and worsened by cyclic loads from the beating heart. Ignoring the multi-modal loading environment in benchtop fatigue tests and computational platforms can lead to undetected potential design defects, calling for redefining consensus evaluation strategies for scaffold performance. With the robust evaluation strategy presented herein, which exploits the results of in-vivo, in-vitro and in-silico investigations, we may be able to compare alternative designs of prototypes at the early stages of device development and optimize the performance of endovascular implants according to patients-specific vessel dynamics and lesion configurations in the future.

A Visualization System for Interactive Exploration of the Cardiac Anatomy

Because of the complex and fine structure, visualization of the heart still remains a challenging task, which makes it an active research topic. In this paper, we present a visualization system for medical data, which takes advantage of the recent graphics processing unit (GPU) and can provide real-time cardiac visualization. This work focuses on investigating the anatomical structure visualization of the human heart, which is fundamental to the cardiac visualization, medical training and diagnosis assistance. Several state-of-the-art cardiac visualization methods are integrated into the proposed system and a task specified visualization method is proposed. In addition, auxiliary tools are provided to generate user specified visualization results. The contributions of our work lie in two-fold: for doctors and medical staff, the system can provide task specified visualization with interactive visualization tools; for researchers, the proposed platform can serve as a baseline for comparing different rendering methods and can easily incorporate new rendering methods. Experimental results show that the proposed system can provide favorable cardiac visualization results in terms of both effectiveness and efficiency.