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Rigatelli G, Zuin M, Marchese G, Rodino G, Hiso E, Mileva N, Vassilev D, Pasquetto G. Residence time in complex left main bifurcation disease after stenting. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:1-5. [PMID: 37996263 DOI: 10.1016/j.carrev.2023.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Data regarding the mean resident time (RT) after left main (LM) bifurcation stenting are scant. In the present study we performed a patient-specific computational fluid dynamic (CFD) analysis to investigate the different post-stenting mean RT values in LM patients treated with single-or double stenting techniques. METHODS Patients were identified after reviewing the local Optical Coherence Tomography (OCT) scans database. Overall, 27 patients (mean age 65.5 ± 12.4, 21 males) [10 patients treated with provisional cross-over stenting, 7 with the double kissing crush (DK crush) and 10 with the nano-inverted T (NIT) technique, respectively] with isolated and significant LM bifurcation disease were analyzed. RESULTS After LM bifurcation stenting, the NIT showed a higher averages WSS values at all bifurcation sites compared to DK crush and provisional cross-over stenting. Moreover, the mean RT resulted lower after NIT compared to provisional or DK crush. During the diastolic phase, the average RT of the entire LM bifurcation was 0.46 s, 0.38 s and 0.33 s after using the provisional stenting, DK crush and NIT, respectively. Moreover, the average RT in the LM bifurcation decreased by 17.1 % using the DK crush and by 28.2 % using the NIT compared to the Provisional. CONCLUSION The present OCT-derived CFD analysis revealed that, in patients with complex bifurcation LM disease, the provisional approach resulted in lower WSS values, while double stenting techniques, especially the NIT technique, resulted in a marked reduction of average RT compared to the provisional approach. CONDENSED ABSTRACT In the present study we performed a patient-specific Optical coherence tomography (OCT)-based computational fluid dynamic (CFD) analysis to investigate the different post-stenting mean RT values in 27 patients treated with provisional cross-over stenting, DK crush and Nano-inverted-T (NIT) stenting. The NIT showed a higher averages WSS values at all bifurcation sites compared to DK crush and Provisional. The mean RT resulted lower in NIT compared to Provisional or DK crush. During the entire diastolic phase, the average RT of the entire LM bifurcation was 0.46 s, 0.38 s and 0.33 s after using the provisional stenting, DK crush and NIT, respectively. Moreover, the average RT in the entire LM bifurcation decreased by 17.1 % using the DK crush and by 28.2 % using the NIT compared to the Provisional.
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Affiliation(s)
- Gianluca Rigatelli
- Interventional Cardiology Unit, Division of Cardiology, Madre Teresa di Calcutta Hospital, AULSS 6, Ospedali Riuniti Padova Sud, Monselice, Italy.
| | - Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Giuseppe Marchese
- Interventional Cardiology Unit, Division of Cardiology, Madre Teresa di Calcutta Hospital, AULSS 6, Ospedali Riuniti Padova Sud, Monselice, Italy
| | - Giulio Rodino
- Interventional Cardiology Unit, Division of Cardiology, Madre Teresa di Calcutta Hospital, AULSS 6, Ospedali Riuniti Padova Sud, Monselice, Italy
| | - Ervis Hiso
- Interventional Cardiology Unit, Division of Cardiology, Madre Teresa di Calcutta Hospital, AULSS 6, Ospedali Riuniti Padova Sud, Monselice, Italy
| | - Niya Mileva
- Department of Cardiology, MedicaCor Hospital, Russe, Bulgaria
| | - Dobrin Vassilev
- Department of Cardiology, MedicaCor Hospital, Russe, Bulgaria
| | - Giampaolo Pasquetto
- Interventional Cardiology Unit, Division of Cardiology, Madre Teresa di Calcutta Hospital, AULSS 6, Ospedali Riuniti Padova Sud, Monselice, Italy
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2
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Sakamoto A, Sato Y, Kawakami R, Cornelissen A, Mori M, Kawai K, Fernandez R, Fuller D, Gadhoke N, Guo L, Romero ME, Kolodgie FD, Virmani R, Finn AV. Risk prediction of in-stent restenosis among patients with coronary drug-eluting stents: current clinical approaches and challenges. Expert Rev Cardiovasc Ther 2021; 19:801-816. [PMID: 33470872 DOI: 10.1080/14779072.2021.1856657] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: In-stent restenosis (ISR) has been one of the biggest limitations to the success of percutaneous coronary intervention for the treatment of coronary artery disease (CAD). The introduction of drug-eluting stent (DES) was a revolution in the treatment of CAD because these devices drastically reduced ISR to very low levels (<5%). Subsequently, newer generation DES treatments have overcome the drawbacks of first-generation DES, i.e. delayed endothelialization, and late stent thrombosis. However, the issue of late ISR, including neoatherosclerosis after DES implantation especially in high-risk patients and complex lesions, still exists as a challenge to be overcome.Areas covered: We discuss the mechanisms of ISR development including neoatherosclerosis, past and current clinical status of ISR, and methods to predict and overcome this issue from pathological and clinical points of view.Expert opinion: The initial drawbacks of first-generation DES, such as delayed endothelial healing and subsequent risk of late stent thrombosis, have been improved upon by the current generation DES. To achieve better long-term clinical outcomes, further titration of drug-release and polymer degradation profile, strut thickness as well as material innovation are needed.
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Affiliation(s)
| | - Yu Sato
- CVPath Institute, Gaithersburg, MD, United States
| | | | | | | | - Kenji Kawai
- CVPath Institute, Gaithersburg, MD, United States
| | | | | | - Neel Gadhoke
- CVPath Institute, Gaithersburg, MD, United States
| | - Liang Guo
- CVPath Institute, Gaithersburg, MD, United States
| | | | | | - Renu Virmani
- CVPath Institute, Gaithersburg, MD, United States
| | - Aloke V Finn
- CVPath Institute, Gaithersburg, MD, United States.,School of Medicine, University of Maryland, Baltimore, MD, United States
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Saito N, Mori Y, Komatsu T. Influence of Stent Flexibility on Artery Wall Stress and Wall Shear Stress in Bifurcation Lesions. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2020; 13:365-375. [PMID: 33173357 PMCID: PMC7646508 DOI: 10.2147/mder.s275883] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/21/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Stent flexibility can influence clinical outcome, especially in bifurcation lesions. For instance, an overly rigid stent can impose mechanical stress on the artery at the stent edges and alter both arterial geometry and blood flow dynamics in bifurcations. This study investigated the influence of stent flexibility on vessel geometry, histology, wall stress, and blood flow dynamics in arterial bifurcations. Materials and Methods We compared arterial angulation, stenosis, histopathology, simulated wall shear stress (WSS), and simulated blood flow velocity distribution in swine coronary artery bifurcations following placement of the less flexible Multi-link 8 or more flexible Kaname stent (4.1 ± 0.5 vs 1.5 ± 0.1 mN, p < 0.05, t-test). Stents were implanted into six coronary artery bifurcations each using the single-stent crossover technique without side branch strut dilatation. Outcomes were examined after 28 days. Results Implantation of both stents significantly increased site angulation (Multi-link 8: 148° ± 8° to 172° ± 2°, p < 0.05, paired t-test; Kaname: 152° ± 5° to 164° ± 4°, p < 0.05, paired t-test), but the change tended to be greater after Multi-link 8 stent implantation (24° ± 15° vs 11° ± 7°, p = 0.1, t-test), suggesting greater straightening of the bifurcation. The Multi-link 8 stent induced greater neointimal thickness than the Kaname stent (0.53 ± 0.3 mm vs 0.26 ± 0.1 mm, p < 0.05, t-test). The distribution of neointimal hyperplasia following stent implantation as revealed by longitudinal histopathology matched the distribution of WSS simulated using computational fluid dynamics (CFD). The endothelium at low WSS areas exhibited aberrant cell morphology and leukocyte adhesion. A CFD model of a curved bifurcation suggested that the region of low WSS is expanded by artery straightening. Conclusion In bifurcated lesions, stent flexibility influences not only mechanical stress on the artery but also WSS, which may induce local neointimal hyperplasia.
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Affiliation(s)
| | - Yuhei Mori
- Terumo Shonan Center, Kanagawa 259-0151, Japan
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4
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Cornelissen A, Guo L, Sakamoto A, Jinnouchi H, Sato Y, Kuntz S, Kawakami R, Mori M, Fernandez R, Fuller D, Gadhoke N, Kolodgie FD, Surve D, Romero ME, Virmani R, Finn AV. Histopathologic and physiologic effect of bifurcation stenting: current status and future prospects. Expert Rev Med Devices 2020; 17:189-200. [PMID: 32101062 DOI: 10.1080/17434440.2020.1733410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Coronary bifurcation lesions are involved in up to 20% of all percutaneous coronary interventions (PCI). However, bifurcation lesion intervention is associated with a high complication rate, and optimal treatment of coronary bifurcation is an ongoing debate.Areas covered: Both different stenting techniques and a variety of devices have been suggested for bifurcation treatment, including the use of conventional coronary stents, bioresorbable vascular scaffolds (BVS), drug-eluting balloons (DEB), and stents dedicated to bifurcations. This review will summarize different therapeutic approaches with their advantages and shortcomings, with special emphasis on histopathologic and physiologic effects of each treatment strategy.Expert opinion: Histopathology and clinical data have shown that a more simple treatment strategy is beneficial in bifurcation lesions, achieving superior results. Bifurcation interventions through balloon angioplasty or placement of stents can importantly alter the bifurcation's geometry and accordingly modify local flow conditions. Computational fluid dynamics (CFD) studies have shown that the outcome of bifurcation interventions is governed by local hemodynamic shear conditions. Minimizing detrimental flow conditions as much as possible should be the ultimate strategy to achieve long-term success of bifurcation interventions.
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Affiliation(s)
- Anne Cornelissen
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA.,Department of Cardiology, Angiology, and Critical Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Liang Guo
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Atsushi Sakamoto
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Hiroyuki Jinnouchi
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Yu Sato
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Salome Kuntz
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Rika Kawakami
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Masayuki Mori
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Raquel Fernandez
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Daniela Fuller
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Neel Gadhoke
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Frank D Kolodgie
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Dipti Surve
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Maria E Romero
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Renu Virmani
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Aloke V Finn
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD, USA.,School of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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5
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Genuardi L, Chatzizisis YS, Chiastra C, Sgueglia G, Samady H, Kassab GS, Migliavacca F, Trani C, Burzotta F. Local fluid dynamics in patients with bifurcated coronary lesions undergoing percutaneous coronary interventions. Cardiol J 2020; 28:321-329. [PMID: 32052855 DOI: 10.5603/cj.a2020.0024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/10/2020] [Accepted: 01/25/2020] [Indexed: 12/14/2022] Open
Abstract
Although the coronary arteries are uniformly exposed to systemic cardiovascular risk factors, atherosclerosis development has a non-random distribution, which follows the local mechanical stresses including flow-related hemodynamic forces. Among these, wall shear stress plays an essential role and it represents the major flow-related factor affecting the distribution of atherosclerosis in coronary bifurcations. Furthermore, an emerging body of evidence suggests that hemodynamic factors such as low and oscillating wall shear stress may facilitate the development of in-stent restenosis and stent thrombosis after successful drug-eluting stent implantation. Drug-eluting stent implantation represents the gold standard for bifurcation interventions. In this specific setting of interventions on bifurcated lesions, the impact of fluid dynamics is expected to play a major role and constitutes substantial opportunity for future technical improvement. In the present review, available data is summarized regarding the role of local fluid dynamics in the clinical outcome of patients with bifurcated lesions.
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Affiliation(s)
- Lorenzo Genuardi
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Yiannis S Chatzizisis
- Cardiovascular Biology and Biomechanics Laboratory, Cardiovascular Division, University of Nebraska Medical Center, Omaha, NE, USA., Omaha, United States
| | - Claudio Chiastra
- Laboratory of Biological Structure Mechanics (LaBS), Chemistry, Materials and Chemical engineering "Giulio Natta" Department, Politecnico di Milano, Milan, Italy, Milan, Italy
| | - Gregory Sgueglia
- Division of Cardiology, Sant'Eugenio Hospital, Rome, Italy, Rome, Italy
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA, Atlanta, United States
| | - Ghassan S Kassab
- California Medical Innovations Institute, San Diego, CA, USA, San Diego, United States
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (LaBS), Chemistry, Materials and Chemical engineering "Giulio Natta" Department, Politecnico di Milano, Milan, Italy, Milan, Italy
| | - Carlo Trani
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Francesco Burzotta
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy, L.go A. Gemelli, 8, 00168 Rome, Italy.
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6
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Rehfuss JP, DeSart KM, Rozowsky JM, O'Malley KA, Moldawer LL, Baker HV, Wang Y, Wu R, Nelson PR, Berceli SA. Hyperacute Monocyte Gene Response Patterns Are Associated With Lower Extremity Vein Bypass Graft Failure. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019. [PMID: 29530886 DOI: 10.1161/circgen.117.001970] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite being the definitive treatment for lower extremity peripheral arterial disease, vein bypass grafts fail in half of all cases. Early repair mechanisms after implantation, governed largely by the immune environment, contribute significantly to long-term outcomes. The current study investigates the early response patterns of circulating monocytes as a determinant of graft outcome. METHODS In 48 patients undergoing infrainguinal vein bypass grafting, the transcriptomes of circulating monocytes were analyzed preoperatively and at 1, 7, and 28 days post-operation. RESULTS Dynamic clustering algorithms identified 50 independent gene response patterns. Three clusters (64 genes) were differentially expressed, with a hyperacute response pattern defining those patients with failed versus patent grafts 12 months post-operation. A second independent data set, comprised of 96 patients subjected to major trauma, confirmed the value of these 64 genes in predicting an uncomplicated versus complicated recovery. Causal network analysis identified 8 upstream elements that regulate these mediator genes, and Bayesian analysis with a priori knowledge of the biological interactions was integrated to create a functional network describing the relationships among the regulatory elements and downstream mediator genes. Linear models predicted the removal of either STAT3 (signal transducer and activator of transcription 3) or MYD88 (myeloid differentiation primary response 88) to shift mediator gene expression levels toward those seen in successful grafts. CONCLUSIONS A novel combination of dynamic gene clustering, linear models, and Bayesian network analysis has identified a core set of regulatory genes whose manipulations could migrate vein grafts toward a more favorable remodeling phenotype.
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Affiliation(s)
- Jonathan P Rehfuss
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Kenneth M DeSart
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Jared M Rozowsky
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Kerri A O'Malley
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Lyle L Moldawer
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Henry V Baker
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Yaqun Wang
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Rongling Wu
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Peter R Nelson
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.)
| | - Scott A Berceli
- From the Malcom Randall Veterans Affairs Medical Center, Gainesville, FL (J.P.R., K.M.D., J.M.R., K.A.O., S.A.B.); Department of Surgery (J.P.R., K.M.D., J.M.R., K.A.O., L.L.M., S.A.B.) and Department of Molecular Genetics and Microbiology (H.V.B.), University of Florida, Gainesville; Department of Biostatistics, Rutgers University, New Brunswick, NJ (Y.W.); Center for Statistical Genetics, Pennsylvania State University, Hershey (R.W.); and Department of Surgery, University of South Florida, Tampa (P.R.N.).
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7
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Menacho J, Rotllant L, Molins JJ, Reyes G, García-Granada AA, Balcells M, Martorell J. Arterial pulse attenuation prediction using the decaying rate of a pressure wave in a viscoelastic material model. Biomech Model Mechanobiol 2017; 17:589-603. [PMID: 29168070 PMCID: PMC5845065 DOI: 10.1007/s10237-017-0980-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/31/2017] [Indexed: 11/30/2022]
Abstract
The present study examines the possibility of attenuating blood pulses by means of introducing prosthetic viscoelastic materials able to absorb energy and damp such pulses. Vascular prostheses made of polymeric materials modify the mechanical properties of blood vessels. The effect of these materials on the blood pulse propagation remains to be fully understood. Several materials for medical applications, such as medical polydimethylsiloxane or polytetrafluoroethylene, show viscoelastic behavior, modifying the original vessel stiffness and affecting the propagation of blood pulses. This study focuses on the propagation of pressure waves along a pipe with viscoelastic materials using the Maxwell and the Zener models. An expression of exponential decay has been obtained for the Maxwell material model and also for low viscous coefficient values in the Zener model. For relatively high values of the viscous term in the Zener model, the steepest part of the pulse can be damped quickly, leaving a smooth, slowly decaying wave. These mathematical models are critical to tailor those materials used in cardiovascular implants to the mechanical environment they are confronted with to repair or improve blood vessel function.
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Affiliation(s)
- J Menacho
- IQS School of Engineering, Universitat Ramon Llull, Via Augusta 390, 08017, Barcelona, Spain
| | - L Rotllant
- IQS School of Engineering, Universitat Ramon Llull, Via Augusta 390, 08017, Barcelona, Spain.,Department of Applied Sciences, CBSET, 500 Shire Way, Lexington, MA, USA
| | - J J Molins
- IQS School of Engineering, Universitat Ramon Llull, Via Augusta 390, 08017, Barcelona, Spain
| | - G Reyes
- IQS School of Engineering, Universitat Ramon Llull, Via Augusta 390, 08017, Barcelona, Spain
| | - A A García-Granada
- IQS School of Engineering, Universitat Ramon Llull, Via Augusta 390, 08017, Barcelona, Spain
| | - M Balcells
- IQS School of Engineering, Universitat Ramon Llull, Via Augusta 390, 08017, Barcelona, Spain. .,IMES - MIT, 77 Massachusetts Av., E25-229, Cambridge, MA, 02139, USA.
| | - J Martorell
- IQS School of Engineering, Universitat Ramon Llull, Via Augusta 390, 08017, Barcelona, Spain
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8
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Ng J, Bourantas CV, Torii R, Ang HY, Tenekecioglu E, Serruys PW, Foin N. Local Hemodynamic Forces After Stenting: Implications on Restenosis and Thrombosis. Arterioscler Thromb Vasc Biol 2017; 37:2231-2242. [PMID: 29122816 DOI: 10.1161/atvbaha.117.309728] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/13/2017] [Indexed: 12/19/2022]
Abstract
Local hemodynamic forces are well-known to modulate atherosclerotic evolution, which remains one of the largest cause of death worldwide. Percutaneous coronary interventions with stent implantation restores blood flow to the downstream myocardium and is only limited by stent failure caused by restenosis, stent thrombosis, or neoatherosclerosis. Cumulative evidence has shown that local hemodynamic forces affect restenosis and the platelet activation process, modulating the pathophysiological mechanisms that lead to stent failure. This article first covers the pathophysiological mechanisms through which wall shear stress regulates arterial disease formation/neointima proliferation and the role of shear rate on stent thrombosis. Subsequently, the article reviews the current evidence on (1) the implications of stent design on the local hemodynamic forces, and (2) how stent/scaffold expansion can influence local flow, thereby affecting the risk of adverse events.
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Affiliation(s)
- Jaryl Ng
- From the National Heart Centre Singapore (J.N., H.Y.A., N.F.); Department of Biomedical Engineering, National University of Singapore, Singapore (J.N.); Departments of Cardiovascular Sciences (C.V.B.) and Mechanical Engineering (R.T.), University College London, United Kingdom; Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (C.V.B.); Thoraxcenter, Erasmus MC, Rotterdam Erasmus University, The Netherlands (E.T., P.W.S.); National Heart & Lung Institute, Imperial College London, United Kingdom (P.W.S.); and Duke-NUS Medical School, National University of Singapore (N.F.)
| | - Christos V Bourantas
- From the National Heart Centre Singapore (J.N., H.Y.A., N.F.); Department of Biomedical Engineering, National University of Singapore, Singapore (J.N.); Departments of Cardiovascular Sciences (C.V.B.) and Mechanical Engineering (R.T.), University College London, United Kingdom; Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (C.V.B.); Thoraxcenter, Erasmus MC, Rotterdam Erasmus University, The Netherlands (E.T., P.W.S.); National Heart & Lung Institute, Imperial College London, United Kingdom (P.W.S.); and Duke-NUS Medical School, National University of Singapore (N.F.)
| | - Ryo Torii
- From the National Heart Centre Singapore (J.N., H.Y.A., N.F.); Department of Biomedical Engineering, National University of Singapore, Singapore (J.N.); Departments of Cardiovascular Sciences (C.V.B.) and Mechanical Engineering (R.T.), University College London, United Kingdom; Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (C.V.B.); Thoraxcenter, Erasmus MC, Rotterdam Erasmus University, The Netherlands (E.T., P.W.S.); National Heart & Lung Institute, Imperial College London, United Kingdom (P.W.S.); and Duke-NUS Medical School, National University of Singapore (N.F.)
| | - Hui Ying Ang
- From the National Heart Centre Singapore (J.N., H.Y.A., N.F.); Department of Biomedical Engineering, National University of Singapore, Singapore (J.N.); Departments of Cardiovascular Sciences (C.V.B.) and Mechanical Engineering (R.T.), University College London, United Kingdom; Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (C.V.B.); Thoraxcenter, Erasmus MC, Rotterdam Erasmus University, The Netherlands (E.T., P.W.S.); National Heart & Lung Institute, Imperial College London, United Kingdom (P.W.S.); and Duke-NUS Medical School, National University of Singapore (N.F.)
| | - Erhan Tenekecioglu
- From the National Heart Centre Singapore (J.N., H.Y.A., N.F.); Department of Biomedical Engineering, National University of Singapore, Singapore (J.N.); Departments of Cardiovascular Sciences (C.V.B.) and Mechanical Engineering (R.T.), University College London, United Kingdom; Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (C.V.B.); Thoraxcenter, Erasmus MC, Rotterdam Erasmus University, The Netherlands (E.T., P.W.S.); National Heart & Lung Institute, Imperial College London, United Kingdom (P.W.S.); and Duke-NUS Medical School, National University of Singapore (N.F.)
| | - Patrick W Serruys
- From the National Heart Centre Singapore (J.N., H.Y.A., N.F.); Department of Biomedical Engineering, National University of Singapore, Singapore (J.N.); Departments of Cardiovascular Sciences (C.V.B.) and Mechanical Engineering (R.T.), University College London, United Kingdom; Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (C.V.B.); Thoraxcenter, Erasmus MC, Rotterdam Erasmus University, The Netherlands (E.T., P.W.S.); National Heart & Lung Institute, Imperial College London, United Kingdom (P.W.S.); and Duke-NUS Medical School, National University of Singapore (N.F.)
| | - Nicolas Foin
- From the National Heart Centre Singapore (J.N., H.Y.A., N.F.); Department of Biomedical Engineering, National University of Singapore, Singapore (J.N.); Departments of Cardiovascular Sciences (C.V.B.) and Mechanical Engineering (R.T.), University College London, United Kingdom; Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (C.V.B.); Thoraxcenter, Erasmus MC, Rotterdam Erasmus University, The Netherlands (E.T., P.W.S.); National Heart & Lung Institute, Imperial College London, United Kingdom (P.W.S.); and Duke-NUS Medical School, National University of Singapore (N.F.).
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9
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Impact of branching angle on neointimal coverage of drug-eluting stents implanted in bifurcation lesions. Coron Artery Dis 2017; 27:682-689. [PMID: 27525716 DOI: 10.1097/mca.0000000000000422] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the impact of branching angle (BA) on neointimal coverage of drug-eluting stents (DESs) in bifurcation lesions. BACKGROUND Previous experimental studies indicated that BA influences the local flow turbulence and wall shear stress, which are associated with neointimal coverage of DESs. METHODS Fifty-five bifurcation lesions in 47 patients were evaluated by serial optical coherence tomography (OCT) before DES implantation and at follow-up. Neointimal coverage was assessed in cross-sectional OCT images containing the side branch; regions including the side branch ostium (SO) and vessel wall (VW) were assessed separately. BA was measured using angiography (Angio-BA) and longitudinal OCT imaging (OCT-BA). RESULTS In the SO region, a significant negative correlation was found between the uncovered strut percentage and Angio-BA or OCT-BA (r=-0.41, P=0.0024; r=-0.33, P=0.0167, respectively) and a significant positive correlation was found between Angio-BA and average neointimal thickness (r=0.31, P=0.025), whereas no correlation was observed between OCT-BA and average neointimal thickness (r=0.20, P=0.158). In the VW region, no correlation was found between Angio-BA or OCT-BA and the uncovered strut percentage or average neointimal thickness. CONCLUSION BA influence the neointimal coverage over DES struts in the SO at coronary bifurcation lesions, but not in those attached to the VW.
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Antoniadis AP, Mortier P, Kassab G, Dubini G, Foin N, Murasato Y, Giannopoulos AA, Tu S, Iwasaki K, Hikichi Y, Migliavacca F, Chiastra C, Wentzel JJ, Gijsen F, Reiber JH, Barlis P, Serruys PW, Bhatt DL, Stankovic G, Edelman ER, Giannoglou GD, Louvard Y, Chatzizisis YS. Biomechanical Modeling to Improve Coronary Artery Bifurcation Stenting. JACC Cardiovasc Interv 2015; 8:1281-1296. [DOI: 10.1016/j.jcin.2015.06.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 06/05/2015] [Accepted: 06/18/2015] [Indexed: 02/04/2023]
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11
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DeSart K, O'Malley K, Schmit B, Lopez MC, Moldawer L, Baker H, Berceli S, Nelson P. Systemic inflammation as a predictor of clinical outcomes after lower extremity angioplasty/stenting. J Vasc Surg 2015; 64:766-778.e5. [PMID: 26054584 DOI: 10.1016/j.jvs.2015.04.399] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 04/18/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The activation state of the systemic inflammatory milieu has been proposed as a critical regulator of vascular repair after injury. We evaluated the early inflammatory response after endovascular intervention for symptomatic peripheral arterial disease to determine its association with clinical success or failure. METHODS Blood samples were obtained from 14 patients undergoing lower extremity angioplasty/stenting and analyzed using high-throughput gene arrays, multiplex serum protein analyses, and flow cytometry. RESULTS Time-dependent plasma protein and monocyte phenotype analyses demonstrated endovascular revascularization had a modest influence on the overall activation state of the systemic inflammatory system, with baseline variability exceeding the perturbations induced by the intervention. In contrast, specific time-dependent changes in the monocyte genome are evident in the initial 28 days, predominately in those genes associated with leukocyte extravasation. Investigating the relationship between inflammation and the 1-year success or failure of the intervention showed no single plasma protein was correlated with outcome, but a more comprehensive cluster analysis revealed a clear pattern of protein expression that was closely related to the clinical phenotype. Corresponding examination of the monocyte genome identified a gene subset at 1 day postprocedure that was predictive of clinical outcome, with most of these genes active in cell-cycle signaling. CONCLUSIONS Although the global influence of angioplasty/stenting on systemic inflammation was modest, circulating cytokine and monocyte genome analyses support a pattern of early inflammation that is associated with ultimate intervention success vs failure. Molecular profiles incorporating genes involved in monocyte cell-cycle progression and homing, or proinflammatory cytokines, or both, offer the most promise for the development of class prediction tools for clinical application.
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Affiliation(s)
- Kenneth DeSart
- Department of Surgery, University of Florida College of Medicine, Gainesville, Fla
| | - Kerri O'Malley
- Department of Surgery, University of Florida College of Medicine, Gainesville, Fla
| | - Bradley Schmit
- Department of Surgery, University of Florida College of Medicine, Gainesville, Fla
| | - Maria-Cecilia Lopez
- Department of Molecular Genetics and Microbiology, University of Florida College of Medicine, Gainesville, Fla
| | - Lyle Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, Fla
| | - Henry Baker
- Department of Molecular Genetics and Microbiology, University of Florida College of Medicine, Gainesville, Fla
| | - Scott Berceli
- Department of Surgery, University of Florida College of Medicine, Gainesville, Fla; Malcom Randall VA Medical Center, Gainesville, Fla
| | - Peter Nelson
- Division of Vascular and Endovascular Surgery, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley VA Medical Center, Tampa, Fla.
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12
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Antoniadis AP, Giannopoulos AA, Wentzel JJ, Joner M, Giannoglou GD, Virmani R, Chatzizisis YS. Impact of local flow haemodynamics on atherosclerosis in coronary artery bifurcations. EUROINTERVENTION 2015; 11 Suppl V:V18-22. [DOI: 10.4244/eijv11sva4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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13
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Favreau JT, Liu C, Yu P, Tao M, Mauro C, Gaudette GR, Ozaki CK. Acute reductions in mechanical wall strain precede the formation of intimal hyperplasia in a murine model of arterial occlusive disease. J Vasc Surg 2014; 60:1340-1347. [PMID: 24139980 PMCID: PMC3989476 DOI: 10.1016/j.jvs.2013.07.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 07/22/2013] [Accepted: 07/27/2013] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Intimal hyperplasia (IH) continues to plague the durability of vascular interventions. Employing a validated murine model, ultrasound biomicroscopy, and speckle-tracking algorithms, we tested the hypothesis that reduced cyclic arterial wall strain results in accentuated arterial wall IH. METHODS A 9-0 suture was tied around the left mouse (n = 10) common carotid artery and a 35-gauge (outer diameter = 0.14 mm) blunt mandrel. We previously showed that mandrel removal results in a ∼78% reduction in diameter and ∼85% reduction in flow, with subsequent delayed induction of IH by day 28. Preoperative, postoperative day-4 (before measurable IH), and postoperative day-27 circumferential wall strains were measured in locations 1, 2, and 3 mm proximal to the stenosis and in the same locations on the contralateral (nonstenosed) carotid. At postoperative day 28, arteries were perfusion fixed and arterial wall morphology was assessed microscopically in the same regions. RESULTS Strains were the same in all locations preoperatively. Wall strain was decreased in all regions proximal to the stenosis by day 4 (0.26 ± 0.01 to 0.11 ± 0.02; P < .001), while strains remained unchanged for the contralateral artery (P = .45). No statistical regional differences in mean strain or IH were noted at any time point for the experimental or contralateral artery. Based on the median, regions were divided into those with low strain (≤0.1) and high strain (>0.1). Average preoperative strains in both groups were the same (0.27 ± 0.09 and 0.27 ± 0.08). All segments in the low-strain group (n = 13) demonstrated significant IH formation by day 28, while only 31% of the high strain group demonstrated any detectable IH at day 28. (Mean low-strain intimal thickness = 32 ± 20 μm, high strain = 8.0 ± 16 μm; P < .01). Changes in cross-sectional area at diastole drove the reduction in strain in the low-strain group, increasing significantly from preoperatively to day 4 (P = .04), while lumen cross-section at systole remained unchanged (P = .46). Cross-sectional area at diastole and systole in the high-strain group remained unchanged from preoperatively to day 4 (P = .67). CONCLUSIONS Early reduction in arterial wall strain is associated with subsequent development of hemodynamically induced IH.
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Affiliation(s)
- John T Favreau
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Mass; Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Chengwei Liu
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass; Division of Vascular Surgery, The First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China
| | - Peng Yu
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Ming Tao
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Christine Mauro
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Glenn R Gaudette
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
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Martorell J, Santomá P, Kolandaivelu K, Kolachalama VB, Melgar-Lesmes P, Molins JJ, Garcia L, Edelman ER, Balcells M. Extent of flow recirculation governs expression of atherosclerotic and thrombotic biomarkers in arterial bifurcations. Cardiovasc Res 2014; 103:37-46. [PMID: 24841070 PMCID: PMC4670884 DOI: 10.1093/cvr/cvu124] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/10/2014] [Accepted: 05/01/2014] [Indexed: 11/12/2022] Open
Abstract
AIMS Atherogenesis, evolution of plaque, and outcomes following endovascular intervention depend heavily on the unique vascular architecture of each individual. Patient-specific, multiscale models able to correlate changes in microscopic cellular responses with relevant macroscopic flow, and structural conditions may help understand the progression of occlusive arterial disease, providing insights into how to mitigate adverse responses in specific settings and individuals. METHODS AND RESULTS Vascular architectures mimicking coronary and carotid bifurcations were derived from clinical imaging and used to generate conjoint computational meshes for in silico analysis and biocompatible scaffolds for in vitro models. In parallel with three-dimensional flow simulations, geometrically realistic scaffolds were seeded with human smooth muscle cells (SMC) or endothelial cells and exposed to relevant, physiological flows. In vitro surrogates of endothelial health, atherosclerotic progression, and thrombosis were locally quantified and correlated best with an quantified extent of flow recirculation occurring within the bifurcation models. Oxidized low-density lipoprotein uptake, monocyte adhesion, and tissue factor expression locally rose up to three-fold, and phosphorylated endothelial nitric oxide synthase and Krüppel-like factor 2 decreased up to two-fold in recirculation areas. Isolated testing in straight-tube idealized constructs subject to static, oscillatory, and pulsatile conditions, indicative of different recirculant conditions corroborated these flow-mediated dependencies. CONCLUSIONS Flow drives variations in vascular reactivity and vascular beds. Endothelial health was preserved by arterial flow but jeopardized in regions of flow recirculation in a quasi-linear manner. Similarly, SMC exposed to flow were more thrombogenic in large recirculating regions. Health, thrombosis, and atherosclerosis biomarkers correlate with the extent of recirculation in vascular cells lining certain vascular geometries.
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Affiliation(s)
- Jordi Martorell
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA Department of Chemical Engineering, IQS School of Engineering, URL, Via Augusta 390, 08017 Barcelona, Spain
| | - Pablo Santomá
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA Department of Chemical Engineering, IQS School of Engineering, URL, Via Augusta 390, 08017 Barcelona, Spain
| | - Kumaran Kolandaivelu
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Vijaya B Kolachalama
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA Charles Stark Draper Laboratory, Cambridge, MA, USA
| | - Pedro Melgar-Lesmes
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - José J Molins
- Department of Chemical Engineering, IQS School of Engineering, URL, Via Augusta 390, 08017 Barcelona, Spain
| | - Lawrence Garcia
- Department of Interventional Cardiology and Vascular Medicine, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mercedes Balcells
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA Department of Biological Engineering, IQS School of Engineering, URL, Barcelona, Spain
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15
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Kolandaivelu K, Leiden BB, Edelman ER. Predicting response to endovascular therapies: Dissecting the roles of local lesion complexity, systemic comorbidity, and clinical uncertainty. J Biomech 2014; 47:908-21. [DOI: 10.1016/j.jbiomech.2014.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 11/25/2022]
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16
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Pathologic Etiologies of Late and Very Late Stent Thrombosis following First-Generation Drug-Eluting Stent Placement. THROMBOSIS 2012; 2012:608593. [PMID: 23227328 PMCID: PMC3512327 DOI: 10.1155/2012/608593] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 10/23/2012] [Indexed: 11/17/2022]
Abstract
Several randomized and observational studies have reported steady increase in cumulative incidence of late and very late ST (LST/VLST) following first-generation drug-eluting stents (DES: sirolimus-(SES) and paclitaxel-(PES)) up to 5 years. Pathologic studies have identified uncovered struts as the primary substrate responsible for LST/VLST following DES, where delayed arterial healing is associated with stent struts penetrating into the necrotic core, long/overlapping stents, and bifurcation stenting especially in flow divider region. Grade V stent fracture also induces LST/VLST and restenosis. Hypersensitivity reaction is exclusive to SES as an etiology of LST/VLST, whereas malapposition secondary to excessive fibrin deposition is associated with PES. Uncovered struts can be identified in SES and PES with duration of implant beyond 12 months, particularly in stents placed for "off-label" indications. Neoatherosclerosis is another important contributing factor for VLST in DES and bare metal stents (BMS); however, DES shows rapid and more frequent development of neoatherosclerosis than BMS. Future pathologic studies should address the long-term safety of newer generation DES including zotarolimus- and everolimus-eluting stents in terms of the improvement in reendothelialization, decreased inflammation and fibrin deposition as well as a lower incidence of stent fracture-related adverse events, and reduced neoatherosclerosis, which likely contribute to the decreased risk of LST/VLST and better patient outcomes.
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17
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Clinical applications of fractional flow reserve in bifurcation lesions. J Geriatr Cardiol 2012; 9:278-84. [PMID: 23097658 PMCID: PMC3470027 DOI: 10.3724/sp.j.1263.2012.05091] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 07/10/2012] [Accepted: 07/11/2012] [Indexed: 02/07/2023] Open
Abstract
Percutaneous coronary intervention (PCI) for coronary bifurcation lesions has been associated with lower procedural success rates and worse clinical outcomes compared with PCI for simple coronary lesions. Angiographic evaluation alone is sometimes inaccurate and does not reflect the functional significance of bifurcation lesions. The fractional flow reserve (FFR) is an easily obtainable, reliable, and reproducible physiologic parameter. This parameter is epicardial lesion specific and reflects both degree of stenosis and the myocardial territory supplied by the specific artery. Recent studies have shown that FFR-guided provisional side branch intervention strategy for bifurcation lesions is feasible and effective and can reduce unnecessary complex interventions and related complications. However, an adequate understanding of coronary physiology and the pitfalls of FFR is essential to properly use FFR for PCI of complex bifurcation lesions.
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18
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Koskinas KC, Chatzizisis YS, Antoniadis AP, Giannoglou GD. Role of endothelial shear stress in stent restenosis and thrombosis: pathophysiologic mechanisms and implications for clinical translation. J Am Coll Cardiol 2012; 59:1337-49. [PMID: 22480478 DOI: 10.1016/j.jacc.2011.10.903] [Citation(s) in RCA: 215] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 09/13/2011] [Accepted: 10/27/2011] [Indexed: 10/28/2022]
Abstract
Restenosis and thrombosis are potentially fatal complications of coronary stenting with a recognized multifactorial etiology. The effect of documented risk factors, however, cannot explain the preponderance of certain lesion types, stent designs, and implantation configurations for the development of these complications. Local hemodynamic factors, low endothelial shear stress (ESS) in particular, are long known to critically affect the natural history of atherosclerosis. Increasing evidence now suggests that ESS may also contribute to the development of restenosis and thrombosis upon stenting of atherosclerotic plaques, in conjunction with well-appreciated risk factors. In this review, we present in vivo and mechanistic evidence associating ESS with the localization and progression of neointimal hyperplasia and in-stent clotting. Clinical studies have associated stent design features with the risk of restenosis. Importantly, computational simulations extend these observations by directly linking specific stent geometry and positioning characteristics with the post-stenting hemodynamic milieu and with the stent's thrombogenicity and pro-restenotic potential, thereby indicating ways to clinical translation. An enhanced understanding of the pathophysiologic role of ESS in restenosis and thrombosis might dictate hemodynamically favorable stent designs and deployment configurations to reduce the potential for late lumen loss and thrombotic obstruction. Recent methodologies for in vivo ESS profiling at a clinical level might allow for early identification of patients at high risk for the development of restenosis or thrombosis and might thereby guide individualized, risk-tailored treatment strategies to prevent devastating complications of endovascular interventions.
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Affiliation(s)
- Konstantinos C Koskinas
- 1st Cardiology Department, AHEPA University Hospital, Aristole University Medical School, Thessaloniki, Greece
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19
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Yazdani SK, Nakano M, Otsuka F, Kolodgie FD, Virmani R. Atheroma and coronary bifurcations: before and after stenting. EUROINTERVENTION 2012; 6 Suppl J:J24-30. [PMID: 21930487 DOI: 10.4244/eijv6supja5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
First generation drug-eluting stents (DES) have significantly improved the treatment options for patients with symptomatic coronary artery disease by decreasing rates of restenosis after percutaneous coronary revascularisation procedures. However, early enthusiasm was tempered by reports of late stent thrombosis, primarily in "off-label" use. In particular, the treatment of atherosclerotic plaques at coronary bifurcations has been challenging for interventional cardiologists regardless of the stent choice due to the underlying nature of the atherosclerotic disease and the use of multiple stents. In this article we illustrate the location and severity of plaque and investigate the healing following both bare metal stents (BMS) and drug-eluting stents (DES) at bifurcations using post-mortem specimens. The presented data will demonstrate that neointimal growth following stent implantation correlate to flow conditions, as there is less underlying atherosclerotic disease at high shear regions and subsequently less neointimal growth is observed in these regions versus low shear regions. The occurrence of late stent thrombosis in DES is also shown to be associated with greater presence of uncovered stent struts at the high shear region, which is likely due to local flow mechanics.
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Affiliation(s)
- Saami K Yazdani
- CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
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20
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Papafaklis MI, Chatzizisis YS, Naka KK, Giannoglou GD, Michalis LK. Drug-eluting stent restenosis: effect of drug type, release kinetics, hemodynamics and coating strategy. Pharmacol Ther 2011; 134:43-53. [PMID: 22212618 DOI: 10.1016/j.pharmthera.2011.12.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 12/07/2011] [Indexed: 11/26/2022]
Abstract
Restenosis following stent implantation diminishes the procedure's efficacy influencing long-term clinical outcomes. Stent-based drug delivery emerged a decade ago as an effective means of reducing neointimal hyperplasia by providing localized pharmacotherapy during the acute phase of the stent-induced injury and the ensuing pathobiological mechanisms. However, drug-eluting stent (DES) restenosis may still occur especially when stents are used in complex anatomical and clinical scenarios. A DES consists of an intravascular metallic frame and carriers which allow controlled release of active pharmaceutical agents; all these components are critical in determining drug distribution locally and thus anti-restenotic efficacy. Furthermore, dynamic flow phenomena characterizing the vascular environment, and shear stress distribution, are greatly influenced by stent implantation and play a significant role in drug deposition and bioavailability within local vascular tissue. In this review, we discuss the performance of DES and the interaction of the different DES components with the hemodynamic milieu emphasizing on the inhibition of clinical restenosis.
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Affiliation(s)
- Michail I Papafaklis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA.
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21
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Rigby KM, DeLeo FR. Neutrophils in innate host defense against Staphylococcus aureus infections. Semin Immunopathol 2011; 34:237-59. [PMID: 22080185 PMCID: PMC3271231 DOI: 10.1007/s00281-011-0295-3] [Citation(s) in RCA: 260] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 10/14/2011] [Indexed: 12/29/2022]
Abstract
Staphylococcus aureus has been an important human pathogen throughout history and is currently a leading cause of bacterial infections worldwide. S. aureus has the unique ability to cause a continuum of diseases, ranging from minor skin infections to fatal necrotizing pneumonia. Moreover, the emergence of highly virulent, drug-resistant strains such as methicillin-resistant S. aureus in both healthcare and community settings is a major therapeutic concern. Neutrophils are the most prominent cellular component of the innate immune system and provide an essential primary defense against bacterial pathogens such as S. aureus. Neutrophils are rapidly recruited to sites of infection where they bind and ingest invading S. aureus, and this process triggers potent oxidative and non-oxidative antimicrobial killing mechanisms that serve to limit pathogen survival and dissemination. S. aureus has evolved numerous mechanisms to evade host defense strategies employed by neutrophils, including the ability to modulate normal neutrophil turnover, a process critical to the resolution of acute inflammation. Here we provide an overview of the role of neutrophils in host defense against bacterial pathogens and discuss strategies employed by S. aureus to circumvent neutrophil function.
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Affiliation(s)
- Kevin M Rigby
- Laboratory of Human Pathogenesis, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, 903 South 4th Street, Hamilton, MT 59840, USA
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Chiu JJ, Chien S. Effects of disturbed flow on vascular endothelium: pathophysiological basis and clinical perspectives. Physiol Rev 2011; 91:327-87. [PMID: 21248169 PMCID: PMC3844671 DOI: 10.1152/physrev.00047.2009] [Citation(s) in RCA: 1375] [Impact Index Per Article: 105.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Vascular endothelial cells (ECs) are exposed to hemodynamic forces, which modulate EC functions and vascular biology/pathobiology in health and disease. The flow patterns and hemodynamic forces are not uniform in the vascular system. In straight parts of the arterial tree, blood flow is generally laminar and wall shear stress is high and directed; in branches and curvatures, blood flow is disturbed with nonuniform and irregular distribution of low wall shear stress. Sustained laminar flow with high shear stress upregulates expressions of EC genes and proteins that are protective against atherosclerosis, whereas disturbed flow with associated reciprocating, low shear stress generally upregulates the EC genes and proteins that promote atherogenesis. These findings have led to the concept that the disturbed flow pattern in branch points and curvatures causes the preferential localization of atherosclerotic lesions. Disturbed flow also results in postsurgical neointimal hyperplasia and contributes to pathophysiology of clinical conditions such as in-stent restenosis, vein bypass graft failure, and transplant vasculopathy, as well as aortic valve calcification. In the venous system, disturbed flow resulting from reflux, outflow obstruction, and/or stasis leads to venous inflammation and thrombosis, and hence the development of chronic venous diseases. Understanding of the effects of disturbed flow on ECs can provide mechanistic insights into the role of complex flow patterns in pathogenesis of vascular diseases and can help to elucidate the phenotypic and functional differences between quiescent (nonatherogenic/nonthrombogenic) and activated (atherogenic/thrombogenic) ECs. This review summarizes the current knowledge on the role of disturbed flow in EC physiology and pathophysiology, as well as its clinical implications. Such information can contribute to our understanding of the etiology of lesion development in vascular niches with disturbed flow and help to generate new approaches for therapeutic interventions.
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Affiliation(s)
- Jeng-Jiann Chiu
- Division of Medical Engineering Research, National Health Research Institutes, Taiwan
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Moore JE, Timmins LH, LaDisa JF. Coronary artery bifurcation biomechanics and implications for interventional strategies. Catheter Cardiovasc Interv 2010; 76:836-43. [DOI: 10.1002/ccd.22596] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Williams AR, Koo BK, Gundert TJ, Fitzgerald PJ, LaDisa JF. Local hemodynamic changes caused by main branch stent implantation and subsequent virtual side branch balloon angioplasty in a representative coronary bifurcation. J Appl Physiol (1985) 2010; 109:532-40. [DOI: 10.1152/japplphysiol.00086.2010] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Abnormal blood flow patterns promoting inflammation, cellular proliferation, and thrombosis may be established by local changes in vessel geometry after stent implantation in bifurcation lesions. Our objective was to quantify altered hemodynamics due to main vessel (MV) stenting and subsequent virtual side branch (SB) angioplasty in a coronary bifurcation by using computational fluid dynamics (CFD) analysis. CFD models were generated from representative vascular dimensions and intravascular ultrasound images. Time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), and fractional flow reserve (FFR) were quantified. None of the luminal surface was exposed to low TAWSS (<4 dyn/cm2) in the nondiseased bifurcation model. MV stenting introduced eccentric areas of low TAWSS along the lateral wall of the MV. Virtual SB angioplasty resulted in a more concentric region of low TAWSS in the MV distal to the carina and along the lateral wall of the SB. The luminal surface exposed to low TAWSS was similar before and after virtual SB angioplasty (rest: 43% vs. 41%; hyperemia: 18% vs. 21%) and primarily due to stent-induced flow alterations. Sites of elevated OSI (>0.1) were minimal but more impacted by general vessel geometry established after MV stenting. FFR measured at a jailed SB was within the normal range despite angiographic stenosis of 54%. These findings indicate that the most commonly used percutaneous interventional strategy for a bifurcation lesion causes abnormal local hemodynamic conditions. These results may partially explain the high clinical event rates in bifurcation lesions.
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Affiliation(s)
- Andrew R. Williams
- Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin
| | - Bon-Kwon Koo
- Center for Cardiovascular Technology, Stanford University Medical Center, Stanford, California
- Seoul National University College of Medicine, Seoul, Korea; and
| | - Timothy J. Gundert
- Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin
| | - Peter J. Fitzgerald
- Center for Cardiovascular Technology, Stanford University Medical Center, Stanford, California
| | - John F. LaDisa
- Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin
- Department of Medicine, Medical College of Wisconsin and
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Tousi N, Wang B, Pant K, Kiani MF, Prabhakarpandian B. Preferential adhesion of leukocytes near bifurcations is endothelium independent. Microvasc Res 2010; 80:384-8. [PMID: 20624406 DOI: 10.1016/j.mvr.2010.07.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 07/02/2010] [Indexed: 11/29/2022]
Abstract
Leukocyte-endothelial interactions play central roles in many pathological conditions. However, the in vivo mechanisms responsible for nonuniform spatial distribution of adhering leukocytes to endothelial cells in microvascular networks are not clear. We used a combination of in vitro and in vivo methodologies to explain of this complex phenomenon. A mouse cremaster muscle model was used to study the spatial distribution of leukocyte-endothelial cell interaction in vivo. A PDMS-based synthetic microvascular network (SMN) device was used to study interactions of functionalized microspheres using a receptor-ligand system in a (endothelial) cell-free environment for the in vitro studies. Our in vivo and in vitro findings indicate that both leukocytes in vivo and microspheres in vitro preferentially adhere near bifurcation (within 1-2 diameters from the bifurcation). This adhesion pattern was found to be independent of the diameter of the vessels. These findings support our hypothesis that the fluidic patterns near bifurcations/junctions, and not the presence or cellular aspects of the system (e.g. cell deformation, cell signaling, heterogeneous distribution of adhesion molecules), is the main controlling factor behind the preferential adhesion patterns of leukocytes near bifurcations.
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Affiliation(s)
- Nazanin Tousi
- Department of Mechanical Engineering, Temple University, Philadelphia, PA, USA
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Godino C, Al-Lamee R, La Rosa C, Morici N, Latib A, Ielasi A, Di Mario C, Sangiorgi GM, Colombo A. Coronary left main and non-left main bifurcation angles: how are the angles modified by different bifurcation stenting techniques? J Interv Cardiol 2010; 23:382-93. [PMID: 20624203 DOI: 10.1111/j.1540-8183.2010.00562.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Investigation of the correlation between bifurcation angles and outcomes is limited with discordant results. The aim of this study is to investigate left main (LM) and non-left main (N-LM) bifurcation angles and their modification after percutaneous coronary intervention (PCI). Measurement of all three angles adds to our understanding of bifurcation anatomy and the resultant effect of different stenting techniques. METHODS AND RESULTS All three bifurcation angles were described according to the European Bifurcation Club definition: the A (proximal bifurcation angle), the B (distal bifurcation angle) and the C (main branch angle). Measurements were performed in 75 LM and 140 N-LM bifurcations. In LM bifurcations baseline mean values of C, A, and B were 151 degrees +/- 28 degrees, 131 degrees +/- 32 degrees, and 78 +/- 28 degrees, respectively. In bifurcations with 2 stents the B significantly decreased by a mean of 10 degrees (P = 0.003) and A increased by 10 degrees (P = 0.006). Crush stenting significantly decreased B (A - 14 degrees ; P = 0.020) and increased A (A + 21 degrees; P = 0.005), particularly non-true bifurcations. In N-LM bifurcations mean values for C, A, and B were 156 degrees +/- 19 degrees , 144 degrees +/- 22 degrees, and 60 degrees +/- 20 degrees, respectively. Similar to LM bifurcations, the B became narrower mainly at the expense of the A, which became wider. In both types of bifurcations the greatest variation in A and B was found following 2-stent techniques performed in T-shaped (> or =70 degrees) bifurcations. CONCLUSIONS In both LM and N-LM bifurcations we found a significant difference in A and B pre- and post-PCI. This difference was driven by the 2-stent technique and was most evident with a baseline bifurcation angle > or =70 degrees. The Crush technique caused the largest angle variation post-procedure, particularly in non-true LM bifurcations.
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Affiliation(s)
- Cosmo Godino
- Interventional Cardiology Unit, San Raffaele Institute, Milan, Italy.
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27
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Pathological Findings at Bifurcation Lesions. J Am Coll Cardiol 2010; 55:1679-87. [DOI: 10.1016/j.jacc.2010.01.021] [Citation(s) in RCA: 187] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 10/20/2009] [Accepted: 01/20/2010] [Indexed: 11/23/2022]
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Kolachalama VB, Levine EG, Edelman ER. Luminal flow amplifies stent-based drug deposition in arterial bifurcations. PLoS One 2009; 4:e8105. [PMID: 19956555 PMCID: PMC2781163 DOI: 10.1371/journal.pone.0008105] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 11/04/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Treatment of arterial bifurcation lesions using drug-eluting stents (DES) is now common clinical practice and yet the mechanisms governing drug distribution in these complex morphologies are incompletely understood. It is still not evident how to efficiently determine the efficacy of local drug delivery and quantify zones of excessive drug that are harbingers of vascular toxicity and thrombosis, and areas of depletion that are associated with tissue overgrowth and luminal re-narrowing. METHODS AND RESULTS We constructed two-phase computational models of stent-deployed arterial bifurcations simulating blood flow and drug transport to investigate the factors modulating drug distribution when the main-branch (MB) was treated using a DES. Simulations predicted extensive flow-mediated drug delivery in bifurcated vascular beds where the drug distribution patterns are heterogeneous and sensitive to relative stent position and luminal flow. A single DES in the MB coupled with large retrograde luminal flow on the lateral wall of the side-branch (SB) can provide drug deposition on the SB lumen-wall interface, except when the MB stent is downstream of the SB flow divider. In an even more dramatic fashion, the presence of the SB affects drug distribution in the stented MB. Here fluid mechanic effects play an even greater role than in the SB especially when the DES is across and downstream to the flow divider and in a manner dependent upon the Reynolds number. CONCLUSIONS The flow effects on drug deposition and subsequent uptake from endovascular DES are amplified in bifurcation lesions. When only one branch is stented, a complex interplay occurs - drug deposition in the stented MB is altered by the flow divider imposed by the SB and in the SB by the presence of a DES in the MB. The use of DES in arterial bifurcations requires a complex calculus that balances vascular and stent geometry as well as luminal flow.
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Affiliation(s)
- Vijaya B Kolachalama
- Biomedical Engineering Center, Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America.
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29
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GIL ROBERTJ, VASSILEV DOBRIN, FORMUSZEWICZ RADOSLAW, RUSICKA-PIEKARZ TERESA, DOGANOV ALEXANDER. The Carina AngleâNew Geometrical Parameter Associated with Periprocedural Side Branch Compromise and the Long-Term Results in Coronary Bifurcation Lesions with Main Vessel Stenting Only. J Interv Cardiol 2009; 22:E1-E10. [DOI: 10.1111/j.1540-8183.2009.00492.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Jiang Z, Yu P, Tao M, Ifantides C, Ozaki CK, Berceli SA. Interplay of CCR2 signaling and local shear force determines vein graft neointimal hyperplasia in vivo. FEBS Lett 2009; 583:3536-40. [PMID: 19822149 DOI: 10.1016/j.febslet.2009.10.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 10/02/2009] [Accepted: 10/05/2009] [Indexed: 11/30/2022]
Abstract
Leukocytes play a central role in vein graft neointimal hyperplasia, which is significantly augmented under low shear conditions. The current concept is that shear force regulates leukocyte adhesion predominately through up-regulation of chemokines and growth factors within the graft wall. Using rabbit and murine vein graft models, we demonstrate that CC chemokine receptor 2/monocyte chemoattractant protein-1 mediated monocyte recruitment and a low shear environment act synergistically to augment neointimal hyperplasia development and removal of either of the conditions leads to a significant reduction in neointimal thickening. We propose a novel concept that the shear stress response element phenotypically stems from the complex interplay of the biological and physical microenvironments.
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Affiliation(s)
- Zhihua Jiang
- Department of Surgery, University of Florida and the Malcom Randall VAMC, United States
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31
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Suzuki N, Angiolillo DJ, Tannenbaum MA, Driesman MH, Smith C, Bikkina M, Meckel CR, Morales CE, Xenopoulos NP, Coletta JE, Bezerra HG, Bass TA, Costa MA. Strategies for drug-eluting stent treatment of bifurcation coronary artery disease in the United States: Insights from the e-Cypher S.T.L.L.R.Trial. Catheter Cardiovasc Interv 2009; 73:890-7. [DOI: 10.1002/ccd.21796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Gutierrez LLP, Maslinkiewicz A, Curi R, de Bittencourt PIH. Atherosclerosis: a redox-sensitive lipid imbalance suppressible by cyclopentenone prostaglandins. Biochem Pharmacol 2008; 75:2245-62. [PMID: 18440492 DOI: 10.1016/j.bcp.2008.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 02/17/2008] [Accepted: 03/06/2008] [Indexed: 01/28/2023]
Abstract
Disorders concerning the metabolism of plasma and intracellular lipids are hallmarks of atherosclerosis. However, failures in proper control of intracellular cholesterol balance, rather than simple cholesterol overloading due to augmented uptake, could fuel atherogenesis. Therefore, the understanding of atherosclerosis-associated lipid alterations, which feed an inflammatory microenvironment in the arterial wall, requires the meticulous investigation of several aspects of lipid synthesis, uptake and export from cells. In this regard, the presence of reactive cysteines in transcription factors and key enzymes of lipid metabolism may dictate cholesterol accumulation, and therefore the progression of vascular disease. The strong inhibitory effect of cysteine-reactant anti-inflammatory cyclopentenone prostaglandins (CP-PGs) over atherosclerosis progression in vivo (LipoCardium technology) symbolizes a new concept of atherosclerosis and its treatment. Results from this laboratory and those from other research groups have unraveled a novel facet in prostaglandin research in that CP-PGs may act as redox signals that guide lipid metabolism in atherosclerosis. By modifying enzymes (e.g., HMG-CoA reductase, ACAT and cholesteryl ester hydrolases) and transcription factors (e.g., NF-kappaB and Keap1) involved in inflammation and lipid metabolism, CP-PGs (especially those of A-series) induce pivotal changes in glutathione and lipid metabolism that completely arrest atherosclerosis progression. Hence, pharmacological manipulation of lipid metabolism by CP-PGs may be a novel and invaluable strategy for treating atherosclerosis. Also, a better understanding of why CP-PGs do not resolve inflammation physiologically may explain many unsolved questions and yield insights into atherogenesis and its termination.
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Affiliation(s)
- Lucila Ludmila Paula Gutierrez
- Laboratory of Cellular Physiology, Department of Physiology, Institute of Basic Health Sciences, Federal University of Rio Grande do Sul, 90050-170 Porto Alegre, RS, Brazil
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Gijsen FJH, Wentzel JJ, Thury A, Lamers B, Schuurbiers JCH, Serruys PW, van der Steen AF. A new imaging technique to study 3-D plaque and shear stress distribution in human coronary artery bifurcations in vivo. J Biomech 2007; 40:2349-57. [PMID: 17335832 DOI: 10.1016/j.jbiomech.2006.12.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 12/05/2006] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Bifurcations of coronary arteries are predilection sites for atherosclerosis and expansive remodeling, the latter being associated with plaque vulnerability. Both are related to blood flow-induced shear stress (SS). We present a new approach to generate 3-D reconstructions of coronary artery bifurcations in vivo and investigate the relationship between SS, wall thickness (WT) and remodeling. METHODS The patient specific 3-D reconstruction of the main branch of the bifurcation was obtained by combining intravascular ultrasound and biplane angiography, and the 3-D lumen of the side branch was based on biplane angiography only. The two data sets were fused and computational methods were applied to determine the SS distribution, using patient derived flow and viscosity data. The intravascular ultrasound data allowed us to measure local WT and remodeling in the main branch. RESULTS The lumen reconstruction procedure was successful and it was shown that the impact of the side branch on SS distribution in the main branch diminished within 3mm. Distal to the bifurcation, two continuous regions in the main branch were identified. In the proximal region, we observed lumen preservation, and expansive remodeling. Although a plaque was observed in the low SS region at the non-divider wall, no relationship between SS and WT was found. In the distal region, we observed lumen narrowing and a significant positive relationship between SS and WT. CONCLUSIONS A new imaging technique was applied to generate a 3-D reconstruction of a human coronary artery bifurcation in vivo. The observed relationship between SS, WT and remodeling in this specific patient illustrates the spatial heterogeneity of the atherosclerosis in the vicinity of arterial bifurcations.
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Affiliation(s)
- Frank J H Gijsen
- Department of Biomedical Engineering, Thoraxcenter, Ee2322, Erasmus MC, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
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Murasato Y, Horiuchi M, Otsuji Y. Three-dimensional modeling of double-stent techniques at the left main coronary artery bifurcation using micro-focus X-ray computed tomography. Catheter Cardiovasc Interv 2007; 70:211-20. [PMID: 17421017 DOI: 10.1002/ccd.21133] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Various double-stent techniques using drug-eluting stents have been proposed to treat the left main coronary artery (LMCA) bifurcation. However, use of these techniques is frequently associated with focal restenosis at the ostium of the left circumflex coronary artery (LCX). OBJECTIVES To examine the results of double-stent techniques, using a silicon model of the LMCA bifurcation and three-dimensional (3D) reconstruction images created with micro-focus X-ray computed tomography (MFCT). METHODS Crush, kissing, and modified T stentings were performed with bare metal stents in a LMCA bifurcation model. The stents were then inspected using MFCT at a minimal resolution of 0.06 mm. RESULTS Gaps in stent apposition to the vessel were observed at the site of stent overlap in the distal LMCA with all stenting techniques. In crush stenting, when the left anterior descending artery stent overlapped the LCX stent, the latter was crushed on the myocardial side of the vessel, and a gap was observed on the nonmyocardial side, at the LCX ostium. When the overlap was reversed, the LCX stent was crushed on the nonmyocardial side and a gap was observed on the myocardial side. In the case of kissing stents, stent overlap created a gap beneath the overlapped portion of the stents. In modified T-stenting, correct positioning of the LCX stent was difficult and MFCT imaging revealed a nonmyocardial gap. CONCLUSIONS Close apposition of the stent to the vessel at the ostium of the LCX is difficult to achieve at the LMCA bifurcation, regardless of which double-stent technique is employed, due to the site's wide bifurcation angle and complex 3D structure. The distribution of plaque and the bifurcation angle should be considered before double-stent deployment, to avoid leaving a gap over significant plaques.
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Affiliation(s)
- Yoshinobu Murasato
- Division of Cardiovascular Medicine, Chikuho Social Insurance Hospital, Nogata, and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.
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Valgimigli M, Malagutti P, Rodriguez Granillo GA, Tsuchida K, Garcia-Garcia HM, van Mieghem CAG, Van der Giessen WJ, De Feyter P, de Jaegere P, Van Domburg RT, Serruys PW. Single-vessel versus bifurcation stenting for the treatment of distal left main coronary artery disease in the drug-eluting stenting era. Clinical and angiographic insights into the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated at Rotterdam Cardiology Hospital (T-SEARCH) registries. Am Heart J 2006; 152:896-902. [PMID: 17070153 DOI: 10.1016/j.ahj.2006.03.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Accepted: 03/20/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Routine drug-eluting stent (DES) implantation has recently improved outcome in patients undergoing percutaneous treatment of left main (LM) coronary artery. However, even in the DES era, distal LM treatment remains an independent predictor of poor outcome. Whether single-vessel stenting (SVS) or bifurcation stenting (BS) should be performed to optimize treatment of such a lesion is unclear. METHODS From April 2002 to June 2004, 94 patients affected by distal LM disease underwent percutaneous intervention at our institution either with SVS (n = 48) or BS (n = 46). The 2 groups were well balanced for all baseline characteristics but the extension of disease in the LM carina. RESULTS After a median follow-up of 587 days (range, 328-1179), the cumulative incidence of MACE was similar between the 2 groups (31% in the BS vs 28% in SVS group, HR 0.96, 95% CI 0.46-1.49, P = .92), with no difference for the composite death/myocardial infarction or target vessel revascularization. After adjustment for confounders, the technique of stenting was not a predictor of either major adverse cardiac events or target vessel revascularization. Angiographic analysis--performed in 81% of eligible patients in SVS and 87% in the BS group--confirmed the equivalency between SVS versus BS. CONCLUSIONS In consecutive patients undergoing catheter-based distal LM intervention, SVS or BS may perform equally under both clinical and angiographic perspective in current DES era.
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Affiliation(s)
- Marco Valgimigli
- Erasmus Medical Center, Thoraxcenter, Rotterdam, The Netherlands
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Abstract
Implantation of expandable stents into stenotic arteries after percutaneous coronary intervention to relieve arterial narrowing has become a standard therapeutic tool. The improvement in vascular interventional technology, and especially stent technology, has, arguably, outstripped understanding of the biologic consequences of opening an obstructed artery. In the case of bifurcation stenoses, new evidence suggests that opening a stenotic subsidiary branch may create unfavorable hemodynamics in the stented main branch that can lead to in-stent restenosis.
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Affiliation(s)
- R Wayne Alexander
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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