Alterations in wall shear stress predict sites of neointimal hyperplasia after stent implantation in rabbit iliac arteries

Restenosis resulting from neointimal hyperplasia (NH) limits the effectiveness of intravascular stents. Rates of restenosis vary with stent geometry, but whether stents affect spatial and temporal distributions of wall shear stress (WSS) in vivo is unknown. We tested the hypothesis that alterations in spatial WSS after stent implantation predict sites of NH in rabbit iliac arteries. Antegrade iliac artery stent implantation was performed under angiography, and blood flow was measured before casting 14 or 21 days after implantation. Iliac artery blood flow domains were obtained from three-dimensional microfocal X-ray computed tomography imaging and reconstruction of the arterial casts. Indexes of WSS were determined using three-dimensional computational fluid dynamics. Vascular histology was unchanged proximal and distal to the stent. Time-dependent NH was localized within the stented region and was greatest in regions exposed to low WSS and acute elevations in spatial WSS gradients. The lowest values of WSS spatially localized to the stented area of a theoretical artery progressively increased after 14 and 21 days as NH occurred within these regions. This NH abolished spatial disparity in distributions of WSS. The results suggest that stents may introduce spatial alterations in WSS that modulate NH in vivo.     

Flow pattern analysis in a highly stenotic patient-specific carotid bifurcation model using a turbulence model

The aim of this study is to investigate the blood flow pattern in carotid bifurcation with a high degree of luminal stenosis, combining in vivo magnetic resonance imaging (MRI) and computational fluid dynamics (CFD). A newly developed two-equation transitional model was employed to evaluate wall shear stress (WSS) distribution and pressure drop across the stenosis, which are closely related to plaque vulnerability. A patient with an 80% left carotid stenosis was imaged using high resolution MRI, from which a patient-specific geometry was reconstructed and flow boundary conditions were acquired for CFD simulation. A transitional model was implemented to investigate the flow velocity and WSS distribution in the patient-specific model. The peak time-averaged WSS value of approximately 73 Pa was predicted by the transitional flow model, and the regions of high WSS occurred at the throat of the stenosis. High oscillatory shear index values up to 0.50 were present in a helical flow pattern from the outer wall of the internal carotid artery immediately after the throat. This study shows the potential suitability of a transitional turbulent flow model in capturing the flow phenomena in severely stenosed carotid arteries using patient-specific MRI data and provides the basis for further investigation of the links between haemodynamic variables and plaque vulnerability. It may be useful in the future for risk assessment of patients with carotid disease.     

Alterations in regional vascular geometry produced by theoretical stent implantation influence distributions of wall shear stress: analysis of a curved coronary artery using 3D computational fluid dynamics modeling

Background  

The success of stent implantation in the restoration of blood flow through areas of vascular narrowing is limited by restenosis. Several recent studies have suggested that the local geometric environment created by a deployed stent may influence regional blood flow characteristics and alter distributions of wall shear stress (WSS) after implantation, thereby rendering specific areas of the vessel wall more susceptible to neointimal hyperplasia and restenosis. Stents are most frequently implanted in curved vessels such as the coronary arteries, but most computational studies examining blood flow patterns through stented vessels conducted to date use linear, cylindrical geometric models. It appears highly probable that restenosis occurring after stent implantation in curved arteries also occurs as a consequence of changes in fluid dynamics that are established immediately after stent implantation.     

Hemodynamics in coronary arteries with overlapping stents

Coronary artery stenosis is commonly treated by stent placement via percutaneous intervention, at times requiring multiple stents that may overlap. Stent overlap is associated with increased risk of adverse clinical outcome. While changes in local blood flow are suspected to play a role therein, hemodynamics in arteries with overlapping stents remain poorly understood. In this study we analyzed six cases of partially overlapping stents, placed ex vivo in porcine left coronary arteries and compared them to five cases with two non-overlapping stents. The stented vessel geometries were obtained by micro-computed tomography of corrosion casts. Flow and shear stress distribution were calculated using computational fluid dynamics. We observed a significant increase in the relative area exposed to low wall shear stress (WSS<0.5 Pa) in the overlapping stent segments compared both to areas without overlap in the same samples, as well as to non-overlapping stents. We further observed that the configuration of the overlapping stent struts relative to each other influenced the size of the low WSS area: positioning of the struts in the same axial location led to larger areas of low WSS compared to alternating struts. Our results indicate that the overlap geometry is by itself sufficient to cause unfavorable flow conditions that may worsen clinical outcome. While stent overlap cannot always be avoided, improved deployment strategies or stent designs could reduce the low WSS burden.     

Hemodynamics in stented vertebral artery ostial stenosis based on computational fluid dynamics simulations

Hemodynamic factors may affect the potential occurrence of in-stent restenosis (ISR) after intervention procedure of vertebral artery ostial stenosis (VAOS). The purpose of the present study is to investigate the influence of stent protrusion length in implantation strategy on the local hemodynamics of the VAOS. CTA images of a 58-year-old female patient with posterior circulation transient ischemic attack were used to perform a 3D reconstruction of the vertebral artery. Five models of the vertebral artery before and after the stent implantation were established. Model 1 was without stent implantation, Model 2–5 was with stent protruding into the subclavian artery for 0, 1, 2, 3 mm, respectively. Computational fluid dynamics simulations based on finite element analysis were employed to mimic the blood flow in arteries and to assess hemodynamic conditions, particularly the blood flow velocity and wall shear stress (WSS). The WSS and the blood flow velocity at the vertebral artery ostium were reduced by 85.33 and 35.36% respectively after stents implantation. The phenomenon of helical flow disappeared. Hemodynamics comparison showed that stent struts that protruded 1 mm into the subclavian artery induced the least decrease in blood speed and WSS. The results suggest that stent implantation can improve the hemodynamics of VAOS, while stent struts that had protruded 1 mm into the subclavian artery would result in less thrombogenesis and neointimal hyperplasia and most likely decrease the risk of ISR.     

Characterization of the in vivo wall shear stress environment of human fetus umbilical arteries and veins

The endothelial cells of the umbilical vessels are frequently used in mechanobiology experiments. They are known to respond to wall shear stress (WSS) of blood flow, which influences vascular growth and remodeling. The in vivo environment of umbilical vascular WSS, however, is not well characterized. In this study, we performed detailed characterization of the umbilical vascular WSS environments using clinical ultrasound scans combined with computational simulations. Doppler ultrasound scans of 28 normal human fetuses from 32nd to 33rd gestational weeks were investigated. Vascular cross-sectional areas were quantified through 3D reconstruction of the vascular geometry from 3D B-mode ultrasound images, and flow velocities were quantified through pulse wave Doppler. WSS in umbilical vein was computed with Poiseuille’s equation, whereas WSS in umbilical artery was obtained via computational fluid dynamics simulations of the helical arterial geometry. Results showed that blood flow velocity for umbilical artery and vein did not correlate with vascular sizes, suggesting that velocity had a very weak trend with or remained constant over vascular sizes. Average WSS for umbilical arteries and vein was 2.81 and 0.52 Pa, respectively. Umbilical vein WSS showed a significant negative correlation with the vessel diameter, but umbilical artery did not show any correlation. We hypothesize that this may be due to differential regulation of vascular sizes based on WSS sensing. Due to the helical geometry of umbilical arteries, bending of the umbilical cord did not significantly alter the vascular resistance or WSS, unlike that in the umbilical veins. We hypothesize that the helical shape of umbilical arteries may be an adaptation feature to render a higher constancy of WSS and flow in the arteries despite umbilical cord bending.     

Influence of non-Newtonian properties of blood on the wall shear stress in human atherosclerotic right coronary arteries

The objective of this work is to investigate the effect of non-Newtonian properties of blood on the wall shear stress (WSS) in atherosclerotic coronary arteries using both Newtonian and non-Newtonian models. Numerical simulations were performed to examine how the spatial and temporal WSS distributions are influenced by the stenosis size, blood viscosity, and flow rate. The computational results demonstrated that blood viscosity properties had considerable effect on the magnitude of the WSS, especially where disturbed flow was observed. The WSS distribution is highly non-uniform both temporally and spatially, especially in the stenotic region. The maximum WSS occurred at the proximal side of the stenosis, near the outer wall in the curved artery with no stenosis. The lumen area near the inner wall distal to the stenosis region experienced a lower WSS during the entire cardiac cycle. Among the factors of stenosis size, blood viscosity, and flow rate, the size of the stenosis has the most significant effect on the spatial and temporal WSS distributions qualitatively and quantitatively.     

Circumferential vascular deformation after stent implantation alters wall shear stress evaluated with time-dependent 3D computational fluid dynamics models.

The success of vascular stents in the restoration of blood flow is limited by restenosis. Recent data generated from computational fluid dynamics (CFD) models suggest that stent geometry may cause local alterations in wall shear stress (WSS) that have been associated with neointimal hyperplasia and subsequent restenosis. However, previous CFD studies have ignored histological evidence of vascular straightening between circumferential stent struts. We tested the hypothesis that consideration of stent-induced vascular deformation may more accurately predict alterations in indexes of WSS that may subsequently account for histological findings after stenting. We further tested the hypothesis that the severity of these alterations in WSS varies with the degree of vascular deformation after implantation. Steady-state and time-dependent simulations of three-dimensional CFD arteries based on canine coronary artery measurements of diameter and blood flow were conducted, and WSS and WSS gradients were calculated. Circumferential straightening introduced areas of high WSS between stent struts that were absent in stented vessels of circular cross section. The area of vessel exposed to low WSS was dependent on the degree of circumferential vascular deformation and axial location within the stent. Stents with four vs. eight struts increased the intrastrut area of low WSS in vessels, regardless of cross-sectional geometry. Elevated WSS gradients were also observed between struts in vessels with polygonal cross sections. The results obtained using three-dimensional CFD models suggest that changes in vascular geometry after stent implantation are important determinants of WSS distributions that may be associated with subsequent neointimal hyperplasia.     

Haemodynamic impact of stent–vessel (mal)apposition following carotid artery stenting: mind the gaps!

Carotid artery stenting (CAS) has emerged as a minimally invasive alternative to endarterectomy but its use in clinical treatment is limited due to the post-stenting complications. Haemodynamic actors, related to blood flow in the stented vessel, have been suggested to play a role in the endothelium response to stenting, including adverse reactions such as in-stent restenosis and late thrombosis. Accessing the flow-related shear forces acting on the endothelium in vivo requires space and time resolutions which are currently not achievable with non-invasive clinical imaging techniques but can be obtained from image-based computational analysis. In this study, we present a framework for accurate determination of the wall shear stress (WSS) in a mildly stenosed carotid artery after the implantation of a stent, resembling the commercially available Acculink (Abbott Laboratories, Abbott Park, Illinois, USA). Starting from angiographic CT images of the vessel lumen and a micro-CT scan of the stent, a finite element analysis is carried out in order to deploy the stent in the vessel, reproducing CAS in silico. Then, based on the post-stenting anatomy, the vessel is perfused using a set of boundary conditions: total pressure is applied at the inlet, and impedances that are assumed to be insensitive to the presence of the stent are imposed at the outlets. Evaluation of the CAS outcome from a geometrical and haemodynamic perspective shows the presence of atheroprone regions (low time-average WSS, high relative residence time) colocalised with stent malapposition and stent strut interconnections. Stent struts remain unapposed in the ostium of the external carotid artery disturbing the flow and generating abnormal shear forces, which could trigger thromboembolic events.     

Hydrodynamic effects of compliance mismatch in stented arteries

Cardiovascular diseases are the number one cause of death in the world, making the understanding of hemodynamics and development of treatment options imperative. The most common modality for treatment of occlusive coronary artery diseases is the use of stents. Stent design profoundly influences the postprocedural hemodynamic and solid mechanical environment of the stented artery. However, despite their wide acceptance, the incidence of stent late restenosis is still high (Zwart et al., 2010, "Coronary Stent Thrombosis in the Current Era: Challenges and Opportunities for Treatment," Current Treatment Options in Cardiovascular Medicine, 12(1), pp. 46-57), and it is most prevailing at the proximal and distal ends of the stent. In this work, we focus our investigation on the localized hemodynamic effects of compliance mismatch due to the presence of a stent in an artery. The compliance mismatch in a stented artery is maximized at the proximal and distal ends of the stent. Hence, it is our objective to understand and reveal the mechanism by which changes in compliance contribute to the generation of nonphysiological wall shear stress (WSS). Such adverse hemodynamic conditions could have an effect on the onset of restenosis. Three-dimensional, spatiotemporally resolved computational fluid dynamics simulations of pulsatile flow with fluid-structure interaction were carried out for a simplified coronary artery with physiologically relevant flow parameters. A model with uniform elastic modulus is used as the baseline control case. In order to study the effect of compliance variation on local hemodynamics, this baseline model is compared with models where the elastic modulus was increased by two-, five-, and tenfold in the middle of the vessel. The simulations provided detailed information regarding the recirculation zone dynamics formed during flow reversals. The results suggest that discontinuities in compliance cause critical changes in local hemodynamics, namely, altering the local pressure and velocity gradients. The change in pressure gradient at the discontinuity was as high as 90%. The corresponding changes in WSS and oscillatory shear index calculated were 9% and 15%, respectively. We demonstrate that these changes are attributed to the physical mechanism associating the pressure gradient discontinuities to the production of vorticity (vorticity flux) due to the presence of the stent. The pressure gradient discontinuities and augmented vorticity flux are affecting the wall shear stresses. As a result, this work reveals how compliance variations act to modify the near wall hemodynamics of stented arteries.     

Local hemodynamic analysis after coronary stent implantation based on Euler-Lagrange method

Coronary stents are deployed to treat the coronary artery disease (CAD) by reopening stenotic regions in arteries to restore blood flow, but the risk of the in-stent restenosis (ISR) is high after stent implantation. One of the reasons is that stent implantation induces changes in local hemodynamic environment, so it is of vital importance to study the blood flow in stented arteries. Based on regarding the red blood cell (RBC) as a rigid solid particle and regarding the blood (including RBCs and plasma) as particle suspensions, a non-Newtonian particle suspensions model is proposed to simulate the realistic blood flow in this work. It considers the blood’s flow pattern and non-Newtonian characteristic, the blood cell-cell interactions, and the additional effects owing to the bi-concave shape and rotation of the RBC. Then, it is compared with other four common hemodynamic models (Newtonian single-phase flow model, Newtonian Eulerian two-phase flow model, non-Newtonian single-phase flow model, non-Newtonian Eulerian two-phase flow model), and the comparison results indicate that the models with the non-Newtonian characteristic are more suitable to describe the realistic blood flow. Afterwards, based on the non-Newtonian particle suspensions model, the local hemodynamic environment in stented arteries is investigated. The result shows that the stent strut protrusion into the flow stream would be likely to produce the flow stagnation zone. And the stent implantation can make the pressure gradient distribution uneven. Besides, the wall shear stress (WSS) of the region adjacent to every stent strut is lower than 0.5 Pa, and along the flow direction, the low-WSS zone near the strut behind is larger than that near the front strut. What’s more, in the regions near the struts in the proximal of the stent, the RBC particle stagnation zone is easy to be formed, and the erosion and deposition of RBCs are prone to occur. These hemodynamic analyses illustrate that the risk of ISR is high in the regions adjacent to the struts in the proximal and the distal ends of the stent when compared with struts in other positions of the stent. So the research can provide a suggestion on the stent design, which indicates that the strut structure in these positions of a stent should be optimized further.

     

Developed pulsatile flow in a deployed coronary stent

The patho-physiologic process of restenosis and tissue growth may not be completely eliminated and is the primary concern of clinicians performing angioplasty and stent implantation procedures. Recent evidence suggests that the restenosis process is influenced by several factors: (1) geometry and size of vessel; (2) stent design; and (3) it's location that alter hemodynamic parameters, including local wall shear stress (WSS) distributions. The present three-dimensional (3D) analysis of pulsatile flow in a deployed coronary stent: (1) shows complex 3D variation of hemodynamic parameters; and (2) quantifies the changes in local WSS distributions for developed flow and compares with recently published WSS data for developing flow. Higher order of magnitude of WSS of 290 dyn/cm(2) is observed on the surface of cross-link intersections at the entrance of the stent for developed flow, which is about half of that for developing flow. Low WSS of 0.8 dyn/cm(2) and negative WSS of -8 dyn/cm(2) are seen at the immediate upstream and downstream regions of strut intersections. Persistent recirculation is observed at the downstream region of each strut cross-link and the regions of low and negative WSS may lead to patho-physiologic conditions near the stented region. The key finding of this study is that the location of stent in the coronary artery determines the developing or developed nature of the flow, which in turn, results in varied level of WSS.     

Mis-sizing of stent promotes intimal hyperplasia: impact of endothelial shear and intramural stress

Stent can cause flow disturbances on the endothelium and compliance mismatch and increased stress on the vessel wall. These effects can cause low wall shear stress (WSS), high wall shear stress gradient (WSSG), oscillatory shear index (OSI), and circumferential wall stress (CWS), which may promote neointimal hyperplasia (IH). The hypothesis is that stent-induced abnormal fluid and solid mechanics contribute to IH. To vary the range of WSS, WSSG, OSI, and CWS, we intentionally mismatched the size of stents to that of the vessel lumen. Stents were implanted in coronary arteries of 10 swine. Intravascular ultrasound (IVUS) was used to size the coronary arteries and stents. After 4 wk of stent implantation, IVUS was performed again to determine the extent of IH. In conjunction, computational models of actual stents, the artery, and non-Newtonian blood were created in a computer simulation to yield the distribution of WSS, WSSG, OSI, and CWS in the stented vessel wall. An inverse relation (R(2) = 0.59, P < 0.005) between WSS and IH was found based on a linear regression analysis. Linear relations between WSSG, OSI, and IH were observed (R(2) = 0.48 and 0.50, respectively, P < 0.005). A linear relation (R(2) = 0.58, P < 0.005) between CWS and IH was also found. More statistically significant linear relations between the ratio of CWS to WSS (CWS/WSS), the products CWS × WSSG and CWS × OSI, and IH were observed (R(2) = 0.67, 0.54, and 0.56, respectively, P < 0.005), suggesting that both fluid and solid mechanics influence the extent of IH. Stents create endothelial flow disturbances and intramural wall stress concentrations, which correlate with the extent of IH formation, and these effects were exaggerated with mismatch of stent/vessel size. These findings reveal the importance of reliable vessel and stent sizing to improve the mechanics on the vessel wall and minimize IH.     

Numerical investigations of the haemodynamic changes associated with stent malapposition in an idealised coronary artery

The deployment of a coronary stent near complex lesions can sometimes lead to incomplete stent apposition (ISA), an undesirable side effect of coronary stent implantation. Three-dimensional computational fluid dynamics (CFD) calculations are performed on simplified stent models (with either square or circular cross-section struts) inside an idealised coronary artery to analyse the effect of different levels of ISA to the change in haemodynamics inside the artery. The clinical significance of ISA is reported using haemodynamic metrics like wall shear stress (WSS) and wall shear stress gradient (WSSG). A coronary stent with square cross-sectional strut shows different levels of reverse flow for malapposition distance (MD) between 0 mm and 0.12 mm. Chaotic blood flow is usually observed at late diastole and early systole for MD=0 mm and 0.12 mm but are suppressed for MD=0.06 mm. The struts with circular cross section delay the flow chaotic process as compared to square cross-sectional struts at the same MD and also reduce the level of fluctuations found in the flow field. However, further increase in MD can lead to chaotic flow not only at late diastole and early systole, but it also leads to chaotic flow at the end of systole. In all cases, WSS increases above the threshold value (0.5 Pa) as MD increases due to the diminishing reverse flow near the artery wall. Increasing MD also results in an elevated WSSG as flow becomes more chaotic, except for square struts at MD=0.06 mm.     

Effects of different stent designs on local hemodynamics in stented arteries

Following the deployment of a coronary stent and disruption of an atheromatous plaque, the deformation of the arterial wall and the presence of the stent struts create a new fluid dynamic field, which can cause an abnormal biological response. In this study 3D computational models were used to analyze the fluid dynamic disturbances induced by the placement of a stent inside a coronary artery. Stents models were first expanded against a simplified arterial plaque, with a solid mechanics analysis, and then subjected to a fluid flow simulation under pulsatile physiological conditions. Spatial and temporal distribution of arterial wall shear stress (WSS) was investigated after the expansion of stents of different designs and different strut thicknesses. Common oscillatory WSS behavior was detected in all stent models. Comparing stent and vessel wall surfaces, maximum WSS values (in the order of 1Pa) were located on the stent surface area. WSS spatial distribution on the vascular wall surface showed decreasing values from the center of the vessel wall portion delimited by the stent struts to the wall regions close to the struts. The hemodynamic effects induced by two different thickness values for the same stent design were investigated, too, and a reduced extension of low WSS region (<0.5Pa) was observed for the model with a thicker strut.     

Computational haemodynamics in two idealised cerebral wide-necked aneurysms after stent placement

Endovascular stents are being commonly used to treat cerebral wide-necked aneurysms recently. The effect of a stent placed in the parent artery is not only to protect the parent artery from occlusion, due to extension of coils and thrombosis, but also to act as flow diverter to vary the haemodynamics in the aneurysm. In this article, two idealised cerebral wide-necked aneurysms were created, one was sidewall aneurysm with curved parent vessel and the other was terminal aneurysm with the bifurcated parent vessel. The plexiglass models of the two aneurysms were 'treated' with commercial porous intravascular stents. The stented physical models were scanned by Micro-CT and the numerical models of the two idealised cerebral wide-necked aneurysms after stent placement were constructed from the scanned image files. The pulsatile flow of non-Newtonian fluid inside the models was simulated by using computational fluid dynamics package. From the simulated flow dynamics, various haemodynamic characteristics such as velocity contours, wall shear stress and oscillatory shear index (OSI) were computed. The velocity of the jet entering the sacs reduced after stent was deployed across the necks of both sidewall and terminal aneurysms; the wall shear stress on the distal neck of sidewall aneurysm reduced, the wall shear stress on the dome of the terminal aneurysm increased and the OSI on the dome of the terminal aneurysm reduced. Therefore, stent placement not only promotes thrombus formation in both aneurysm models but also reduces the regrowth risk of the sidewall aneurysm and the rupture risk of the terminal aneurysm.     

Computational haemodynamics in two idealised cerebral wide-necked aneurysms after stent placement

Endovascular stents are being commonly used to treat cerebral wide-necked aneurysms recently. The effect of a stent placed in the parent artery is not only to protect the parent artery from occlusion, due to extension of coils and thrombosis, but also to act as flow diverter to vary the haemodynamics in the aneurysm. In this article, two idealised cerebral wide-necked aneurysms were created, one was sidewall aneurysm with curved parent vessel and the other was terminal aneurysm with the bifurcated parent vessel. The plexiglass models of the two aneurysms were ‘treated’ with commercial porous intravascular stents. The stented physical models were scanned by Micro-CT and the numerical models of the two idealised cerebral wide-necked aneurysms after stent placement were constructed from the scanned image files. The pulsatile flow of non-Newtonian fluid inside the models was simulated by using computational fluid dynamics package. From the simulated flow dynamics, various haemodynamic characteristics such as velocity contours, wall shear stress and oscillatory shear index (OSI) were computed. The velocity of the jet entering the sacs reduced after stent was deployed across the necks of both sidewall and terminal aneurysms; the wall shear stress on the distal neck of sidewall aneurysm reduced, the wall shear stress on the dome of the terminal aneurysm increased and the OSI on the dome of the terminal aneurysm reduced. Therefore, stent placement not only promotes thrombus formation in both aneurysm models but also reduces the regrowth risk of the sidewall aneurysm and the rupture risk of the terminal aneurysm.     

A numerical assessment of wall shear stress changes after endovascular stenting

This theoretical/numerical study aims at assessing the haemodynamic changes induced by endovascular stenting. By using the classical one-dimensional linear pressure waves theory in elastic vessels, we first show that the modulus of the reflection coefficient induced by an endovascular prosthesis is most likely small since it is proportional to the stent-to-wavelength ratio. As a direct consequence, the wall motion of the elastic (stented) artery can be prescribed a priori and the coupled fluid-structure problem does not have to be solved for assessing the haemodynamic changes due to stenting. Several 2D axisymetric calculations are performed to solve the unsteady incompressible Navier-Stokes equations on moving meshes for different types of (stented) arteries. The numerical results suggest that endovascular stenting increases the systo-diastolic variations of the wall shear stress (by 35% at the middle of the stent, by almost 50% in the proximal transition region). Additional calculations show that over-dilated stents produce less haemodynamic perturbations. Indeed, the increase of the amplitude of the wall shear stress variations over the cardiac cycle is only 10% when the stent radius is equal to the radius of the elastic artery at systole (instead of being equal to the mean artery radius).     

Comparison of physiological and post-endovascular aneurysm repair infrarenal blood flow

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms results in redirection of blood through the deployed endograft (EG). Even though EVAR is clinically effective, the absolute flow restoration is not warranted. Our purpose was to compare the physiological with the post-EVAR infrarenal flow conditions. We developed patient-specific models based on computed tomography data of five healthy volunteers and ten patients treated with the Endurant^® stent-graft system. Wall shear stress (WSS), helicity, pressure and velocity fields were calculated using computational fluid dynamics. The results showed a decrease of peak WSS on the part of the EG that resides in the iliac arteries, compared to the physiological value (p = 0.01). At the abdominal part, the average helicity seems to increase after EVAR, while at the iliac arteries part, the intensity of helical flow seems physiological. Pressure drop and peak velocity in the iliac arteries part are lower than the physiological values (p = 0.04). The comparison revealed that most hemodynamic properties converge to normal levels at the abdominal part whereas statistically significant variations were observed in the iliac arteries part. The delineation of the differences between physiological and postoperative flow data could pave the way for the improvement of EG designs.     

Blood flow in stented arteries: a parametric comparison of strut design patterns in three dimensions

BACKGROUND: Restenosis after stent implantation varies with stent design. Alterations in secondary flow patterns and wall shear stress (WSS) can modulate intimal hyperplasia via their effects on platelet and inflammatory cell transport toward the wall, as well as direct effects on the endothelium. METHOD OF APPROACH: Detailed flow characteristics were compared by estimating the WSS in the near-strut region of realistic stent designs using three-dimensional computational fluid dynamics (CFD), under pulsatile high and low flow conditions. The stent geometry employed was characterized by three geometric parameters (axial strut pitch, strut amplitude, and radius of curvature), and by the presence or lack of the longitudinal connector. RESULTS: Stagnation regions were localized around stent struts. The regions of low WSS are larger distal to the strut. Under low flow conditions, the percentage restoration of mean axial WSS between struts was lower than that for the high flow by 10-12%. The largest mean transverse shear stresses were 30-50% of the largest mean axial shear stresses. The percentage restoration in WSS in the models without the longitudinal connector was as much as 11% larger than with the connector The mean axial WSS restoration between the struts was larger for the stent model with larger interstrut spacing. CONCLUSION: The results indicate that stent design is crucial in determining the fluid mechanical environment in an artery. The sensitivity of flow characteristics to strut configuration could be partially responsible for the dependence of restenosis on stent design. From a fluid dynamics point of view, interstrut spacing should be larger in order to restore the disturbed flow; struts should be oriented to the flow direction in order to reduce the area of flow recirculation. Longitudinal connectors should be used only as necessary, and should be parallel to the axis. These results could guide future stent designs toward reducing restenosis.