Low WSS Induces Intimal Thickening, while Large WSS Variation and Inflammation Induce Medial Thinning, in an Animal Model of Atherosclerosis

Hemodynamics indicates differences between patients with and without a stroke outcome after left ventricular assist device implantation

Stroke remains a leading cause of complications and mortality in heart failure patients treated with a Left Ventricular Assist Device (LVAD). Hemodynamics plays a central role underlying post-LVAD stroke risk and etiology. Yet, detailed quantitative assessment of hemodynamic variables and their relation to stroke outcomes in patients on LVAD support remains a challenge. Modalities for pre-implantation assessment of post-implantation hemodynamics can help address this challenge. We present an in silico hemodynamics analysis for a digital twin cohort 12 patients on LVAD support; 6 with reported stroke outcomes and 6 without. For each patient we created a post-implant twin with the LVAD outflow graft reconstructed from cardiac-gated CT images; and a pre-implant twin of an estimated baseline flow by removing the LVAD outflow graft and driving flow from the aortic valve opening. Hemodynamics was characterized using descriptors for helical flow, vortex generation, and wall shear stress. We observed higher average values for descriptors of positive helical flow, vortex generation, and wall shear stress, across the 6 cases with stroke outcomes when compared with cases without stroke. When the descriptors for LVAD-driven flow were compared against estimated pre-implantation flow, extent of positive helicity was higher, and vorticity and wall shear were lower in cases with stroke compared to those without. Our study suggests that quantitative analysis of hemodynamics after LVAD implantation; and hemodynamic alterations from a pre-implant flow scenario, can potentially reveal hidden information linked to stroke outcomes during LVAD support. This has broad implications on understanding stroke etiology; and using patient digital twins for LVAD treatment planning, surgical optimization, and efficacy assessment.

Hemodynamics in Cerebral Aneurysms and Parent Arteries With Incompletely Expanded Flow Diverter Stents

Braided stents for cerebral aneurysms, including flow diverter stent (FDS), may exhibit incomplete stent expansion (IncompSE) during deployment, depending on factors related to the parent artery. Poor stent apposition due to IncompSE can increase the risk of complications or incomplete aneurysm occlusion. Since hemodynamics may play a critical role in these adverse events, we investigated hemodynamic parameters associated with IncompSE using computational fluid dynamics (CFD) analysis. Three basic geometries were generated to represent an aneurysm located on the siphon of the internal carotid artery. CFD analysis was conducted for each geometry under a total of 12 patterns, including before deployment, complete stent expansion (CompSE), and IncompSE on the distal and proximal sides. We focused on hemodynamic parameters reported to influence occlusion or complications after FDS deployment. The change rate (CR) of these parameters was calculated by comparing conditions before and after FDS deployment. In the cases of CompSE, volume flow (VF) into the aneurysm and maximum wall shear stress (WSS) on the aneurysmal wall decreased on average by 52.7% and 34.7%, respectively. Conversely, in the cases of IncompSE, higher VF, inflow jets, and vortices were observed within the aneurysm. Increased WSS at the aneurysmal neck and parent artery was also noted. While static pressure on the aneurysmal wall and energy loss through the aneurysm region showed minimal change in the case of CompSE, both parameters increased in cases of IncompSE. These findings suggest that IncompSE may result in hemodynamic conditions that are suboptimal for treatment. IncompSE of FDS can potentially induce unfavorable hemodynamic changes, including increased blood flow into the aneurysm and elevated pressure on the aneurysmal wall compared to pre-deployment conditions.

Hemodynamics Indicates Differences Between Patients With And Without A Stroke Outcome After Left Ventricular Assist Device Implantation

Stroke remains a leading cause of complications and mortality in heart failure patients treated with a Left Ventricular Assist Device (LVAD). Hemodynamics plays a central role underlying post-LVAD stroke risk and etiology. Yet, detailed quantitative assessment of hemodynamic variables and their relation to stroke outcomes in patients on LVAD support remains a challenge. Modalities for pre-implantation assessment of post-implantation hemodynamics can help address this challenge. We present an in silico hemodynamics analysis for a digital twin cohort 12 patients on LVAD support; 6 with reported stroke outcomes and 6 without. For each patient we created a post-implant twin with the LVAD outflow graft reconstructed from cardiac-gated CT images; and a pre-implant twin of an estimated baseline flow by removing the LVAD outflow graft and driving flow from the aortic valve opening. Hemodynamics was characterized using descriptors for helical flow, vortex generation, and wall shear stress. We observed higher average values for descriptors of positive helical flow, vortex generation, and wall shear stress, across the 6 cases with stroke outcomes when compared with cases without stroke. When the descriptors for LVAD-driven flow were compared against estimated pre-implantation flow, extent of positive helicity was higher, and vorticity and wall shear were lower in cases with stroke compared to those without. Our study suggests that quantitative analysis of hemodynamics after LVAD implantation; and hemodynamic alterations from a pre-implant flow scenario, can potentially reveal hidden information linked to stroke outcomes during LVAD support. This has broad implications on understanding stroke etiology; and using patient digital twins for LVAD treatment planning, surgical optimization, and efficacy assessment.

Comparison of stable carotid plaques in patients with mild-to-moderate carotid stenosis with vulnerable plaques in patients with significant carotid stenosis

To compare the characteristics of stable and vulnerable carotid plaques, and investigate the diagnostic performance of wall shear stress (WSS) based on magnetic resonance plaque imaging in carotid plaques. Retrospectively analyzed and divided 64 atherosclerotic plaques into stable carotid plaque groups with mild-to-moderate stenosis and vulnerable carotid plaque groups with significant stenosis. Computational fluid dynamics simulations were performed to calculate WSS parameters by using three-dimensional wall geometry based on high-resolution magnetic resonance plaque imaging of carotid bifurcation and patient specific boundary conditions obtained through color Doppler ultrasound. WSS parameters including upstream (WSSup), downstream (WSSdown), and core (WSScore) of plaque. The WSS parameters values were compared between the stable and vulnerable carotid plaque groups. Receiver operating characteristic curves and area under the curve (ROC-AUC) and Python were used to evaluate discriminative efficacy of WSS. WSSdown exhibited significant decrease in the vulnerable carotid plaque group (2.88 ± 0.41 Pa) compared to the stable carotid plaque group (4.47 ± 0.84 Pa) (P = .003). The difference of WSSup (3.28 ± 0.85 Pa vs 4.02 ± 0.74 Pa) and WSScore (1.12 ± 0.18 Pa vs 1.38 ± 0.38 Pa) between the two groups were also pronounced (P = .02, 0.01, respectively). The ROC-AUC values for WSSup, WSSdown, WSScore were 0.75 (95% CI, 0.58-0.93), 0.96 (95% CI, 0.79-1.14), 0.69 (95% CI, 0.56-0.83) respectively. When the value of WSSdown was 3.5 Pa, the sensitivity was 93.7% (95% CI, 76.1-111), specificity and accuracy was 87.5% (95% CI, 70.0-105), 88.4% (95% CI, 70.6-105) respectively. Notably, among these parameters, WSSdown demonstrated the highest discriminative efficiency with a F1 Score of 0.90, Diagnostic Odds Ratio of 105.0 and Matthews Correlation Coefficient of 0.81. Vulnerable carotid plaques with significant stenosis have lower WSS compared to stable plaques with mild-to-moderate stenosis, and downstream WSS showing the highest diagnostic efficacy.

Association between Carotid Bifurcation Angle and Vulnerable Plaque Volume Using Black Blood Magnetic Resonance Imaging

The morphology of the internal carotid artery (ICA) bifurcation is increasingly being recognized as the cause of atherosclerosis and vulnerable plaque leading to cerebral infarction. In this study, we investigated the relationship between carotid bifurcation angle and carotid plaque volume evaluated using black blood magnetic resonance imaging (BB-MRI). Among the 90 patients who underwent revascularization for atherosclerotic symptomatic carotid stenosis between April 2016 and October 2022 using BB-MRI, carotid plaque was evaluated in 57 patients. Relative overall signal intensity (roSI) was defined as the signal intensity of the plaque on T1-weighted images relative to the signal intensity of the sternocleidomastoid muscle in the same slice as the common carotid bifurcation. Regions showing roSI ≥ 1.0 were defined as plaque, and the plaque volume and relative plaque volume were measured from roSI ≥1.0 to ≥2.0 in 0.1 increments. We calculated the angles between the common carotid artery (CCA) and the ICA and between the CCA and the external carotid artery (ECA) on magnetic resonance angiography. We classified two groups according to carotid bifurcation angles based on the ICA angle: Group A = <35° and Group B = ≥35°. Compared with Group A (n = 42), Group B (n = 15) showed a greater relative plaque volume between roSI ≥ 1.3 and roSI ≥ 1.5. A significant correlation was identified between relative plaque volume with roSI ≥ 1.4 and ICA angle (p = 0.049). Vulnerable plaque was significantly more frequent in the group with an ICA angle of ≥35. Moreover, the ICA angle was significantly greater in patients with a roSI of ≥1.4.

Quantitative Assessment of Aortic Hemodynamics for Varying Left Ventricular Assist Device Outflow Graft Angles and Flow Pulsation

Left ventricular assist devices (LVADs) comprise a primary treatment choice for advanced heart failure patients. Treatment with LVAD is commonly associated with complications like stroke and gastro-intestinal (GI) bleeding, which adversely impacts treatment outcomes, and causes fatalities. The etiology and mechanisms of these complications can be linked to the fact that LVAD outflow jet leads to an altered state of hemodynamics in the aorta as compared to baseline flow driven by aortic jet during ventricular systole. Here, we present a framework for quantitative assessment of aortic hemodynamics in LVAD flows realistic human vasculature, with a focus on quantifying the differences between flow driven by LVAD jet and the physiological aortic jet when no LVAD is present. We model hemodynamics in the aortic arch proximal to the LVAD outflow graft, as well as in the abdominal aorta away from the LVAD region. We characterize hemodynamics using quantitative descriptors of flow velocity, stasis, helicity, vorticity and mixing, and wall shear stress. These are used on a set of 27 LVAD scenarios obtained by parametrically varying LVAD outflow graft anastomosis angles, and LVAD flow pulse modulation. Computed descriptors for each of these scenarios are compared against the baseline flow, and a detailed quantitative characterization of the altered state of hemodynamics due to LVAD operation (when compared to baseline aortic flow) is compiled. These are interpreted using a conceptual model for LVAD flow that distinguishes between flow originating from the LVAD outflow jet (and its impingement on the aorta wall), and flow originating from aortic jet during aortic valve opening in normal physiological state.

Location matters: Offset in tissue-engineered vascular graft implantation location affects wall shear stress in porcine models

Objective

Although surgical simulation using computational fluid dynamics has advanced, little is known about the accuracy of cardiac surgical procedures after patient-specific design. We evaluated the effects of discrepancies in location for patient-specific simulation and actual implantation on hemodynamic performance of patient-specific tissue-engineered vascular grafts (TEVGs) in porcine models.

Methods

Magnetic resonance angiography and 4-dimensional (4D) flow data were acquired in porcine models (n = 11) to create individualized TEVGs. Graft shapes were optimized and manufactured by electrospinning bioresorbable material onto a metal mandrel. TEVGs were implanted 1 or 3 months postimaging, and postoperative magnetic resonance angiography and 4D flow data were obtained and segmented. Displacement between intended and observed TEVG position was determined through center of mass analysis. Hemodynamic data were obtained from 4D flow analysis. Displacement and hemodynamic data were compared using linear regression.

Results

Patient-specific TEVGs were displaced between 1 and 8 mm during implantation compared with their surgically simulated, intended locations. Greater offset between intended and observed position correlated with greater wall shear stress (WSS) in postoperative vasculature (P < .01). Grafts that were implanted closer to their intended locations showed decreased WSS.

Conclusions

Patient-specific TEVGs are designed for precise locations to help optimize hemodynamic performance. However, if TEVGs were implanted far from their intended location, worse WSS was observed. This underscores the importance of not only patient-specific design but also precision-guided implantation to optimize hemodynamics in cardiac surgery and increase reproducibility of surgical simulation.

Atomic force microscopy application to study of the biomechanical properties of the aortic intima in the context of early atherosclerosis

Atherosclerosis is characterized by the infiltration of macrophages, accumulation of lipids, activation of endothelial cells and synthesis of extracellular matrix by vascular smooth muscle cells. However, there have been few atomic force microscopy (AFM) studies of the aortic intima in situ in the context of atherosclerosis. By employing a customized liquid cell for AFM, we investigated the aortic intima obtained from male C57BL/6 ApoE-deficient mice (ApoE^-/- ) aged 14 weeks and male C57BL/6 ApoE-sufficient mice (ApoE^+/+ ) aged between 18 and 26 weeks that were fed a high-fat and high-cholesterol diet for 4 weeks and performed force spectroscopy mapping of the biomechanical properties of the intima. In the aortas of ApoE-deficient mice, the intima became stiffer than that of ApoE-sufficient mice. In addition, the cytoskeleton of endothelial cells was enlarged, and extracellular matrix accumulated. The biomechanical properties of the aortic intima are altered in early atherogenesis, which may be induced by the enlargement of the endothelial cell cytoskeleton and the increased synthesis of extracellular matrix by activated smooth muscle cells.

Research on the effect of visceral artery Aneurysm's cardiac morphological variation on hemodynamic situation based on time-resolved CT-scan and computational fluid dynamics

BACKGROUND AND OBJECTIVE

Muscular arteries and related aneurysms keep deforming during the cardiac cycle. However, current patient-specific computational fluid dynamics (CFD) analyses of aneurysms are usually based on individual cardiac phase images. The cardiac deformation and displacement characteristics of muscle arteries and aneurysms, as well as their impact on CFD results, have not been adequately explored. The present study tried to illustrate the cardiac morphological variation of visceral muscular arteries (VMAs) & aneurysms (VAAs) and evaluate its influence on the hemodynamic situation at lesion locations.

METHODS

Four-dimensional computed tomography angiogram (4D-CTA) images of six patients with VAAs were acquired. Medical image registration is used to capture cardiac variations of VMAs. The steady-state CFD simulation is performed on twelve different time-phase geometries. Deformation, displacement, wall shear stress (WSS), velocity, and pressure values at pathological locations are compared to illustrate the deforming characteristics of VAAs and their influence on CFD simulation results.

RESULTS

The deformation and displacement characteristics of lesion locations for six specific patients show a pulsatile pattern. Maximum displacements are always less than 4 mm. The ratio fluctuations of endovascular cavity volume and vascular inner wall surface area, which were employed to depict cardiac deformation, are always less than 20%. According to CFD simulations based on deformed VMAs, WSS has a larger coefficient of variation (COV) than velocity and pressure. Except for one patient's WSS, the COVs of different hemodynamic parameters obtained from simulation results are always less than 10%.

CONCLUSIONS

Based on 4D-CTA images, we confirmed that cardiovascular circulation has a periodic impact on the morphologic characteristics of VMAs. A wave that has extended throughout the studied region is observed. It has a dominant influence on the displacement of VMAs. According to CFD results, the influence of the VMAs' deformation and displacement on different hemodynamic parameters is distinct. The variance in WSS is more prominent compared to pressure and velocity. On most occasions, the influence of the VMAs' periodic deformation and displacement on simulation results is insignificant. However, the variant simulation results induced by deforming VMAs cannot be simply ignored.

Creating patient-specific vein models to characterize wall shear stress in hemodialysis population

End-Stage Renal Disease (ESRD) patients require arteriovenous fistulas (AVF) that allow a mature vein to withstand hemodialysis. Unfortunately, venous thrombosis and stenosis in the cephalic vein arch after AVF placement is common and heavily influenced by hemodynamics. To better assess forces and flow behavior in the cephalic arch, we have built patient-specific millifluidic models that allow us to explore the complex interplay between patient-specific vein geometry and fluctuating hemodynamics. These 3D models were created from patient-specific intravascular ultrasound and venogram images obtained three- and twelve-months post AVF creation and fabricated into soft elastomer-based millifluidic devices. Geometric validation of fabricated phantom millifluidic device shows successful replication of original computational 3D model. Millifluidic devices were perfused with a blood-mimicking fluid containing fluorescent tracer beads under steady-state physiologic cephalic vein flow conditions (20 mL/min). Particle image velocimetry was employed to calculate wall shear stress (WSS) across the cephalic arches. Experimental WSS profile evaluation reveals that the physiologic cephalic arch model yields WSS values within physiologic range [76–760 mPa]. Moreover, upon comparing WSS profiles across all models, it is noticeable that WSS values increase as vein diameter decreases, which further supports employed experimental and analysis strategy. The presented millifluidic devices show promise for experimental WSS characterization under pathologic flow conditions to contrast from calculated physiologic hemodynamics and better understand WSS influence on thrombosis and stenosis in hemodialysis patients.

Multidirectional wall shear stress promotes advanced coronary plaque development: comparing five shear stress metrics

Aims

Atherosclerotic plaque development has been associated with wall shear stress (WSS). However, the multidirectionality of blood flow, and thus of WSS, is rarely taken into account. The purpose of this study was to comprehensively compare five metrics that describe (multidirectional) WSS behaviour and assess how WSS multidirectionality affects coronary plaque initiation and progression.

Methods and results

Adult familial hypercholesterolaemic pigs (n = 10) that were fed a high-fat diet, underwent imaging of the three main coronary arteries at three-time points [3 (T₁), 9 (T₂), and 10–12 (T₃) months]. Three-dimensional geometry of the arterial lumen, in combination with local flow velocity measurements, was used to calculate WSS at T₁ and T₂. For analysis, arteries were divided into 3 mm/45° sectors (n = 3648). Changes in wall thickness and final plaque composition were assessed with near-infrared spectroscopy–intravascular ultrasound, optical coherence tomography imaging, and histology. Both in pigs with advanced and mild disease, the highest plaque progression rate was exclusively found at low time-averaged WSS (TAWSS) or high multidirectional WSS regions at both T₁ and T₂. However, the eventually largest plaque growth was located in regions with initial low TAWSS or high multidirectional WSS that, over time, became exposed to high TAWSS or low multidirectional WSS at T₂. Besides plaque size, also the presence of vulnerable plaque components at the last time point was related to low and multidirectional WSS. Almost all WSS metrics had good predictive values for the development of plaque (47–50%) and advanced fibrous cap atheroma (FCA) development (59–61%).

Conclusion

This study demonstrates that low and multidirectional WSS promote both initiation and progression of coronary atherosclerotic plaques. The high-predictive values of the multidirectional WSS metrics for FCA development indicate their potential as an additional clinical marker for the vulnerable disease.

Coronary arteries hemodynamics: effect of arterial geometry on hemodynamic parameters causing atherosclerosis

Coronary arteries have high curvatures, and hence, flow through them causes disturbed flow patterns, resulting in stenosis and atherosclerosis. This in turn decreases the myocardial flow perfusion, causing myocardial ischemia and infarction. Therefore, in order to understand the mechanisms of these phenomena caused by high curvatures and branching of coronary arteries, we have conducted elaborate hemodynamic analysis for both (i) idealized coronary arteries with geometrical parameters representing realistic curvatures and stenosis and (ii) patient-specific coronary arteries with stenoses. Firstly, in idealized coronary arteries with approximated realistic arterial geometry representative of their curvedness and stenosis, we have computed the hemodynamic parameters of pressure drop, wall shear stress (WSS) and wall pressure gradient (WPG), and their association with the geometrical parameters of curvedness and stenosis. Secondly, we have similarly determined the wall shear stress and wall pressure gradient distributions in four patient-specific curved stenotic right coronary arteries (RCAs), which were reconstructed from medical images of patients diagnosed with atherosclerosis and stenosis; our results show high WSS and WPG regions at the stenoses and inner wall of the arterial curves. This paper provides useful insights into the causative mechanisms of the high incidence of atherosclerosis in coronary arteries. It also provides guidelines for how simulation of blood flow in patient's coronary arteries and determination of the hemodynamic parameters of WSS and WPG can provide a medical assessment of the risk of development of atherosclerosis and plaque formation, leading to myocardial ischemia and infarction. The novelty of our paper is in our showing how in actual coronary arteries (based on their CT imaging) curvilinearity and narrowing complications affect the computed WSS and WPG, associated with risk of atherosclerosis. This is very important for cardiologists to be able to properly take care of their patients and provide remedial measures before coronary complications lead to myocardial infarctions and necessitate stenting or coronary bypass surgery. We want to go one step further and provide clinical application of our research work. For that, we are offering to cardiologists worldwide to carry out hemodynamic analysis of the medically imaged coronary arteries of their patients and compute the values of the hemodynamic parameters of WSS and WPG, so as to provide them an assessment of the risk of atherosclerosis for their patients. Graphical abstract Theme and aims: Coronary arteries have high curvatures, and hence flow through them causes disturbed flow patterns, resulting in stenosis and atherosclerosis. This in turn decreases the myocardial flow perfusion, causing myocardial ischemia and infarction. Therefore, in order to understand the mechanisms of these phenomena caused by high curvatures and branching of coronary arteries, we have conducted elaborate hemodynamic analysis for both (i) idealized coronary arteries with geometrical parameters representing curvatures and stenosis, and (ii) patient-specific coronary arteries with stenoses. Methods and results: Firstly, in idealized coronary arteries with approximated realistic arterial geometry representative of their curvedness and stenosis, we have computed the hemodynamic parameters of pressure drop, wall shear stress (WSS) and wall pressure gradient (WPG), and their association with the geometrical parameters of curvedness and stenosis. Then, we have determined the wall shear stress and wall pressure gradient distributions in four patient-specific curved stenotic right coronary arteries (RCAs), that were reconstructed from medical images of patients diagnosed with atherosclerosis and stenosis, as illustrated in Figure 1, in which the locations of the stenoses are highlighted by arrows. Figure 1: Three-dimensional CT visualization of arteries in patients with suspected coronary disease. The arteries can be seen as a combination of various curved segments with stenoses at unspecific locations highlighted by arrows. Our results show high WSS and WPG regions at the stenoses and inner wall of the arterial curves, as depicted in Figure 2. Therein, the encapsulations show (i) high WSS, and (ii) high WPG regions at the stenosis and inner wall of the arterial curves. Figure 2: WSS and WPG surface plot of realistic arteries (a), (b), (c) and (d), wherein the small squared parts are enlarged to show the detailed localized contour plots at the stenotic regions. Therein, the circular encapsulations show (i) high WSS and (ii) high WPG regions at the stenosis and inner wall of the arterial curves. Conclusion and novelty: This paper provides useful insights into the causative mechanisms of the high incidence of atherosclerosis in coronary arteries. It also provides guidelines for how simulation of blood flow in patient coronary arteries and determination of the hemodynamic parameters of WSS and WPG can provide a medical assessment of the risk of development of atherosclerosis and plaque formation, leading to myocardial ischemia and infarction. The novelty of our paper is our showing how in actual coronary arteries (based on their CT imaging), curvilinearity and narrowing complications affect the computed WSS and WPG associated with risk of atherosclerosis. This is very important for cardiologists to be able to properly take care of their patients and provide remedial measures before coronary complications lead to myocardial infarctions and necessitate stenting or coronary bypass surgery.

Label-free photoacoustic and ultrasound imaging for murine atherosclerosis characterization

Dual-modality photoacoustic tomography (PAT) and 4D ultrasound (4DUS) imaging have shown promise for cardiovascular applications, but their use in murine atherosclerosis imaging is limited. This study used PAT and 4DUS to correlate altered arterial strain and hemodynamics to morphological changes and lipid localization in a murine partial carotid ligation (PCL) model of atherosclerosis. Validation experiments showed a positive correlation between the PAT signal-to-noise ratio and plaque lipid composition obtained from oil-red O histology. Cross-sectional in situ PAT and longitudinal in vivo ultrasound imaging was performed using a 40 MHz transducer. Ultrasound timepoints included days 0, 1, 4, 7, 10, and 14 for hemodynamic and strain assessment, and 1100 nm and 1210 nm PAT was implemented at the study end point for hemoglobin and lipid characterization. These study groups were then separated into day 4 post-PCL with (n = 5) and without (n = 6) Western diet feeding, as well as days 7 (n = 8), 10 (n = 8), and 14 (n = 8) post-PCL, in addition to a sham control group on a Western diet (n = 5). Overall, our data revealed a substantial decrease in left carotid artery pulsatility by day 7. The hemodynamic results suggested greater disturbed flow in the caudal regions resulting in earlier vessel stenosis and greater lipid deposition than cranial regions. Morphological and compositional data revealed heterogeneous vascular remodeling between days 0 and 7, with a rapid decrease in the vessel volume/length and the presence of both intraplaque hematoma and lipid deposition at day 10 post-PCL. These results highlight the utility of utilizing dual-modality PAT and 4DUS to study atherosclerosis progression.

Assessment of the Hemodynamics of Autogenous Arteriovenous Fistulas With 4D Phase Contrast-Based Flow Quantification MRI in Dialysis Patients

BACKGROUND

Regular monitoring of autogenous arteriovenous fistulas (AVFs) for hemodialysis patients has importance. Hence, 4D flow MRI may be an alternative for assessing the hemodynamics of AVFs.

PURPOSE

To compare the hemodynamics of AVFs using Doppler ultrasound (DUS) and 4D-MRI in renal dialysis patients.

STUDY TYPE

Case-control study from October 2017 to April 2018.

POPULATION

Fifty patients (age [range] = 59.52 [39-71] years) with AVFs were included.

FIELD STRENGTH/SEQUENCE

Black-blood MRI and 4D flow MRI at 3.0T and AVF ultrasonography were also performed.

ASSESSMENT

The hemodynamics acquired from 4D flow MRI and ultrasonography by two radiologists were compared. The AVF anatomy was described through an examination of the black-blood MRI.

STATISTICAL TESTS

The consistency of AVF anatomy and hemodynamics and the consistency of the hemodynamics of AVFs from 4D flow MRI and ultrasound were analyzed by paired t-tests. The morphological parameters of AVFs acquired from black-blood MRI were used for a Pearson correlation analysis with the hemodynamic parameters obtained from 4D flow MRI data.

RESULTS

The consistency of the morphological and hemodynamic parameters measured from MRI by the two radiologists was good (all P < 0.01). The velocities and flow volumes from the 4D flow MRI and vascular ultrasound of AVFs were in moderate agreement (all P < 0.05, r = 0.292-0.569), except for the peak flow velocity at the anastomosis (P = 0.366, r = -0.078). The flow volume and WSS near the anastomotic site were closely related to the morphology of the AVFs (all P < 0.05). The hemodynamics of the complications group were significantly different from those of patients without any complications (normal patients group) (all P < 0.01).

DATA CONCLUSION

Compared with ultrasonography, 4D flow MRI is a promising technique to noninvasively estimate the AVF hemodynamics of renal dialysis patients.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:1272-1280.

The mechanics of spiral flow: Enhanced washout and transport

Spiral/helical forms of blood flow have been observed in large arteries of the cardiovascular system, but their benefits remain underappreciated. Spiral flow has been postulated to improve near-wall washout, promoting anti-atherothrombotic conditions. This research aims to study the washout characteristics of spiral flow, specifically, its ability to increase velocity and wall shear stress (WSS) in atherothrombotic-prone regions. Using 1.2 cm diameter angled test-conduits (45°, 90°, 135°) with known recirculation/stasis regions at the bend corners, spiral flow washout potential was evaluated in terms of low velocity and low WSS. Two sub-studies were conducted: the first utilized a spiral flow-inducing device to enable qualitative analysis of washout-potential in both computational fluid dynamic (CFD) simulations and benchtop ultrasound visualization; the second used CFD to study the impact of several induced helical wavelengths on the conduit-dependent recirculation/stasis zones. Physical models of the angled conduits and spiral flow-inducer were 3D-printed to facilitate ultrasound visualization. Compared to straight flow, spiral flow generated by the flow-inducer significantly cleared the recirculation/stasis zones at the corners of the angled conduits. CFD simulations demonstrated that past a geometry-dependent threshold, increased helical content improved washout, denoted by decreased regions of low velocity and low WSS. Overall, spiral flow markedly improved washout in difficult to reach areas in the angled conduits. This has several important clinical implications: spiral flow shows great promise in reducing blood-transport-related complications and can be used to enhance the performance of future medical devices (eg grafts, mechanical circulatory support devices, hemodialysis access ports).

Mathematical Modelling and Simulation of Atherosclerosis Formation and Progress: A Review

Cardiovascular disease (CVD) is a major threat to human health since it is the leading cause of death in western countries. Atherosclerosis is a type of CVD related to hypertension, diabetes, high levels of cholesterol, smoking, oxidative stress, and age. Atherosclerosis primarily occurs in medium and large arteries, such as coronary and the carotid artery and, in particular, at bifurcations and curvatures. Atherosclerosis is compared to an inflammatory disease where a thick, porous material comprising cholesterol fat, saturated sterols, proteins, fatty acids, calcium etc., is covered by an endothelial membrane and a fragile fibrous tissue which makes atheromatic plaque prone to rupture that could lead to the blockage of the artery due to the released plaque material. Despite the great progress achieved, the nature of the disease is not fully understood. This paper reviews the current state of modelling of all levels of atherosclerosis formation and progress and discusses further challenges in atherosclerosis modelling. The objective is to pave a way towards more precise computational tools to predict and eventually reengineer the fate of atherosclerosis.

Current and Emerging Preclinical Approaches for Imaging-Based Characterization of Atherosclerosis

Atherosclerotic plaques can remain quiescent for years, but become life threatening upon rupture or disruption, initiating clot formation in the vessel lumen and causing acute myocardial infarction and ischemic stroke. Whether and how a plaque ruptures is determined by its macroscopic structure and microscopic composition. Rupture-prone plaques usually consist of a thin fibrous cap with few smooth muscle cells, a large lipid core, a dense infiltrate of inflammatory cells, and neovessels. Such lesions, termed high-risk plaques, can remain asymptomatic until the thrombotic event. Various imaging technologies currently allow visualization of morphological and biological characteristics of high-risk atherosclerotic plaques. Conventional protocols are often complex and lack specificity for high-risk plaque. Conversely, new imaging approaches are emerging which may overcome these limitations. Validation of these novel imaging techniques in preclinical models of atherosclerosis is essential for effective translational to clinical practice. Imaging the vessel wall, as well as its biological milieu in small animal models, is challenging because the vessel wall is a small structure that undergoes continuous movements imposed by the cardiac cycle as it is adjacent to circulating blood. The focus of this paper is to provide a state-of-the-art review on techniques currently available for preclinical imaging of atherosclerosis in small animal models and to discuss the advantages and limitations of each approach.

Fluid-Structure Interaction in Abdominal Aortic Aneurysms: Effect of Haematocrit

The Abdominal Aortic Aneurysm (AAA) is a local dilation of the abdominal aorta and it is a cause for serious concern because of the high mortality associated with its rupture. Consequently, the understanding of the phenomena related to the creation and the progression of an AAA is of crucial importance. In this work, the complicated interaction between the blood flow and the AAA wall is numerically examined using a fully coupled Fluid-Structure Interaction (FSI) method. The study investigates the possible link between the dynamic behavior of an AAA and the blood viscosity variations attributed to the haematocrit value, while it also incorporates the pulsatile blood flow, the non-Newtonian behavior of blood and the hyperelasticity of the arterial wall. It was found that blood viscosity has no significant effect on von Mises stress magnitude and distribution, whereas there is a close relation between the haematocrit value and the Wall Shear Stress (WSS) magnitude in AAAs. This WSS variation can possibly alter the mechanical properties of the arterial wall and increase its growth rate or even its rupture possibility. The relationship between haematocrit and dynamic behavior of an AAA can be helpful in designing a patient specific treatment.

Enhancement of measurement accuracy of X-ray PIV in comparison with the micro-PIV technique

The X-ray PIV (particle image velocimetry) technique has been used as a non-invasive measurement modality to investigate the haemodynamic features of blood flow. However, the extraction of two-dimensional velocity field data from the three-dimensional volumetric information contained in X-ray images is technically unclear. In this study, a new two-dimensional velocity field extraction technique is proposed to overcome technological limitations. To resolve the problem of finding a correction coefficient, the velocity field information obtained by X-ray PIV and micro-PIV techniques for disturbed flow in a concentric stenosis with 50% severity was quantitatively compared. Micro-PIV experiments were conducted for single-plane and summation images, which provide similar positional information of particles as X-ray images. The correction coefficient was obtained by establishing the relationship between velocity data obtained from summation images (V_S) and centre-plane images (V_C). The velocity differences between V_S and V_C along the vertical and horizontal directions were quantitatively analysed as a function of the geometric angle of the test model for applying the present two-dimensional velocity field extraction technique to a conduit of arbitrary geometry. Finally, the two-dimensional velocity field information at arbitrary positions could be successfully extracted from X-ray images by using the correction coefficient and several velocity parameters derived from V_S.

Effect of intraplaque angiogenesis to atherosclerotic rupture-prone plaque induced by high shear stress in rabbit model

Atherosclerotic prone-rupture plaque is mainly localized in the region of the entrance to the stenosis with high shear stress and the reasons are largely unknown. Our hypothesis is that such a distribution of cells in atherosclerotic plaque may depend on the angiogenesis. Silastic collars induced regions of high shear stress (20.68 ± 5.27 dynes/cm²) in the upstream flow and low shear stress (12.25 ± 1.28 dynes/cm²) in the downstream flow in carotid arteries. Compared with the low shear stress region, plaques in the high shear stress region showed more intraplaque haemorrhaging, less collagen and higher apoptotic rates of vascular smooth muscle cells; endothelial cells (ECs) in the high shear stress region were characterized with integrity and high endothelial nitric oxide synthase (eNOS) expression (1570.3 ± 345.5% vs 172.9 ± 49.9%). The number of intraplaque microvessels is very high in the high shear stress region (15 ± 1.8 n/mm² vs 3.5 ± 0.4 n/mm²), and the microvessels in the plaque show ECs were abnormal, with membrane blebs, intracytoplasmic vacuoles and leukocyte infiltration. Our current study reveals that the integrity of the endothelium and the vulnerability of atherosclerotic plaques are simultaneously localized in high shear stress regions, and we provide evidence for the first time that microvessels in the intraplaque maybe responsible for rupture-prone plaque formation in the high shear stress region.

Endothelial glycocalyx as a critical signalling platform integrating the extracellular haemodynamic forces and chemical signalling

The glycocalyx covers the human mammalian cells and plays important roles in stroke, inflammation and atherosclerosis. It has also been shown to be involved in endothelial mechanotransduction of shear stress. Shear stress induces the remodelling of the major component of the glycocalyx including glypican‐1, a cell membrane heparan sulphate proteoglycan. Other factors, such as sphingosine‐1‐phosphate (S1P), protect the glycocalyx against syndecan‐1 ectodomain shedding and induce the synthesis of heparan sulphate. In this study, we reviewed the role of shear stress and S1P in glycocalyx remodelling and revealed that the glycocalyx is a critical signalling platform, integrating the extracellular haemodynamic forces and chemical signalling, such as S1P, for determining the fate of endothelial cells and vascular diseases. This review integrated our current understanding of the structure and function of the glycocalyx and provided new insight into the role of the glycocalyx that might be helpful for investigating the underlying biological mechanisms in certain human diseases, such as atherosclerosis.

In vivo measurement of hemodynamic information in stenosed rat blood vessels using X-ray PIV

Measurements of the hemodynamic information of blood flows, especially wall shear stress (WSS), in animal models with circulatory vascular diseases (CVDs) are important to understand the pathological mechanism of CVDs. In this study, X-ray particle image velocimetry (PIV) with high spatial resolution was applied to obtain velocity field information in stenosed blood vessels with high WSS. 3D clips fabricated with a 3D printer were applied to the abdominal aorta of a rat cadaver to induce artificial stenosis in the real blood vessel of an animal model. The velocity and WSS information of blood flows in the stenosed vessel were obtained and compared at various stenosis severities. In vivo measurement was also conducted by fastening a stenotic clip on a live rat model through surgical intervention to reduce the flow rate to match the limited temporal resolution of the present X-ray PIV system. Further improvement of the temporal resolution of the system might be able to provide in vivo measurements of hemodynamic information from animal disease models under physiological conditions. The present results would be helpful for understanding the relation between hemodynamic characteristics and the pathological mechanism in animal CVD models.