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

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

Comparison of the hemodynamics in 6mm and 4-7 mm hemodialysis grafts by means of CFD

The aim of our study is to investigate with computational fluid dynamics (CFD) whether different arterial anastomotic geometries result in a different hemodynamics at the arterial (AA) and venous anastomosis (VA) of hemodialysis vascular access grafts. We have studied a 6mm graft (CD) and a 4-7 mm graft (TG). A validated three-dimensional CFD model is developed to simulate flow in the two graft types. Only the arterial anastomosis (AA) geometry differs. The boundary conditions applied are a periodic velocity signal at the arterial inlet and a periodic pressure wave at the venous outlet. Flow rate is set to 1,000 ml/min. The time dependent Navier-Stokes equations are solved. Wall shear stress (WSS), wall shear stress gradient (WSSG) and pressure gradient (PG) are calculated. Anastomotic flow is asymmetric although the anastomosis geometry is symmetric. The hemodynamic parameters, WSS, WSSG and PG, values at the suture line of the arterial anastomosis of the TG are at least twice as much as in the CD. Comparing the parameters at the two AA indicate that little flow rate increase introduces the risk of hemolysis in the TG whereas the CD is completely free of hemolysis. The hemodynamic parameter values at the venous anastomosis of the CD are 24 till 35% higher compared to the values of the TG. WSS values (> 3 Pa) in the VA are in the critical range for stenosis development in both graft geometries. The zones where the parameters reach extreme values correspond to the locations where intimal hyperplasia formation is reported in literature. In all anastomoses, the hemodynamic parameter levels are in the range where leucocytes and platelets get activated. Our simulations confirm clinical results where TG did not show a better outcome when compared to the CD.     

Flow patterns in three-dimensional porcine epicardial coronary arterial tree

The branching pattern of epicardial coronary arteries is clearly three-dimensional, with correspondingly complex flow patterns. The objective of the present study was to perform a detailed hemodynamic analysis using a three-dimensional finite element method in a left anterior descending (LAD) epicardial arterial tree, including main trunk and primary branches, based on computed tomography scans. The inlet LAD flow velocity was measured in an anesthetized pig, and the outlet pressure boundary condition was estimated based on scaling laws. The spatial and temporal wall shear stress (WSS), gradient of WSS (WSSG), and oscillatory shear index (OSI) were calculated and used to identify regions of flow disturbances in the vicinity of primary bifurcations. We found that low WSS and high OSI coincide with disturbed flows (stagnated, secondary, and reversed flows) opposite to the flow divider and lateral to the junction orifice of the main trunk and primary branches. High time-averaged WSSG occurs in regions of bifurcations, with the flow divider having maximum values. Low WSS and high OSI were found to be related through a power law relationship. Furthermore, zones of low time-averaged WSS and high OSI amplified for larger diameter ratio and high inlet flow rate. Hence, different focal atherosclerotic-prone regions may be explained by different physical mechanism associated with certain critical levels of low WSS, high OSI, and high WSSG, which are strongly affected by the diameter ratio. The implications of the flow patterns for atherogenesis are enumerated.     

Intimal hyperplasia and wall shear in arterial bypass graft distal anastomoses: an in vivo model study

The observation of intimal hyperplasia at bypass graft anastomoses has suggested a potential interaction between local hemodynamics and vascular wall response. Wall shear has been particularly implicated because of its known effects upon the endothelium of normal vessels and, thus, was examined as to its possible role in the development of intimal hyperplasia in arterial bypass graft distal anastomoses. Tapered (4-7 mm I.D.) e-PTFE synthetic grafts 6 cm long were placed as bilateral carotid artery bypasses in six adult, mongrel dogs weighing between 25 and 30 kg with distal anastomotic graft-to-artery diameter ratios (DR) of either 1.0 or 1.5. Immediately following implantation, simultaneous axial velocity measurements were made in the toe and artery floor regions in the plane of the anastomosis at radial increments of 0.35 mm, 0.70 mm, and 1.05 mm using a specially designed 20 MHz triple crystal ultrasonic wall shear rate transducer Mean, peak, and pulse amplitude wall shear rates (WSRs), their absolute values, the spatial and temporal wall shear stress gradients (WSSG), and the oscillatory shear index (OSI) were computed from these velocity measurements. All grafts were harvested after 12 weeks implantation and measurements of the degree of intimal hyperplasia (IH) were made along the toe region and the artery floor of the host artery in 1 mm increments. While some IH occurred along the toe region (8.35+/-23.1 microm) and was significantly different between DR groups (p<0.003), the greatest amount occurred along the artery floor (81.6+/-106.5 microm, mean +/- S.D.) (p < 0.001) although no significant differences were found between DR groups. Linear regressions were performed on the paired IH and mean, peak, and pulse amplitude WSR data as well as the absolute mean, peak, and pulse amplitude WSR data from all grafts. The mean and absolute mean WSRs showed a modest correlation with IH (r = -0.406 and -0.370, respectively) with further improvements seen (r = -0.482 and -0.445, respectively) when using an exponential relationship. The overall best correlation was seen against an exponential function of the OSI (r = 0.600). Although these correlation coefficients were not high, they were found to be statistically significant as evidenced by the large F-statistic obtained. Finally, it was observed that over 75 percent of the IH occurred at or below a mean WSR value of 100 s(-1) while approximately 92 percent of the IH occurred at or below a mean WSR equal to one-half that of the native artery. Therefore, while not being the only factor involved, wall shear (and in particular, oscillators wall shear) appears to provide a stimulus for the development of anastomotic intimal hyperplasia.     

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.     

Simulation of flow through a Miller cuff bypass graft

Unnatural temporal and spatial distributions of wall shear stress in the anastomosis of distal bypass grafts have been identified as possible factors in the development of anastomotic intimal hyperplasia in these grafts. Distal bypass graft anastomoses with an autologus vein cuff (a Miller cuff) interposed between the graft and artery have been shown to alleviate the effects of intimal hyperplasia. In this study, pulsatile flow through models of a standard end-to-side anastomosis and a Miller cuff anastomosis are computed and the resulting wall shear stress and pressure distributions analysed. The results are inconclusive, and could be taken to suggest that the unnatural distributions of shear stress that do occur along the anastomosis floor may not be particularly important in the development of intimal hyperplasia. However, it seems more likely that the positive effects of the biological and material properties of the vein cuff, which are not considered in this study, somehow outweigh the negative effects of the shear stress distributions predicted to occur on the floor of the Miller-cuff graft.     

Simulation of Flow through a Miller Cuff Bypass Graft

Unnatural temporal and spatial distributions of wall shear stress in the anastomosis of distal bypass grafts have been identified as possible factors in the development of anastomotic intimal hyperplasia in these grafts. Distal bypass graft anastomoses with an autologus vein cuff (a Miller cuff) interposed between the graft and artery have been shown to alleviate the effects of intimal hyperplasia. In this study, pulsatile flow through models of a standard end-to-side anastomosis and a Miller cuff anastomosis are computed and the resulting wall shear stress and pressure distributions analysed. The results are inconclusive, and could be taken to suggest that the unnatural distributions of shear stress that do occur along the anastomosis floor may not be particularly important in the development of intimal hyperplasia. However, it seems more likely that the positive effects of the biological and material properties of the vein cuff, which are not considered in this study, somehow outweigh the negative effects of the shear stress distributions predicted to occur on the floor of the Miller-cuff graft.     

Analysis of blood flow in an out-of-plane CABG model

Coronary artery bypass graft (CABG) is a routine surgical treatment for ischemic and infarcted myocardium. A large number of CABG fail postoperatively because of intimal hyperplasia within months or years. The cause of this failure is thought to be partly related to the flow patterns and shear stresses acting on the endothelial cells. An accurate representation of the flow field and associated wall shear stress (WSS) requires a detailed three-dimensional (3D) model of the CABG. The purpose of this study is to present a detailed analysis of blood flow in a 3D aorto/left CABG, bypassing the occluded left anterior descending coronary (LAD) artery. The analysis takes into account the influence of the out-of-plane geometry of the graft. The finite volume technique was employed to model the 3D blood flow pattern to determine the velocity and WSS distributions. This study presents the flow field distributions of the velocity and WSS at four instances of the cardiac cycle, two in systole and two in diastole. Our results reveal that the CABG geometry has a significant effect on the velocity distribution. The axial velocity profiles at different instances of the cardiac cycle exhibit strong skewing; significant secondary flow and vortex structures are seen in the in-plane velocity patterns. The maximum WSS on the bed of the occluded LAD artery opposite to the graft junction is 14 Pa in middiastole, whereas there is a significantly lower and more uniform distribution of WSS on the bed of the anastomosis. The present results indicate that nonplanarity of the blood vessel along with the inflow conditions has a substantial effect on the fluid mechanics of CABG that contribute to the patency of graft.     

An S-type bypass can improve the hemodynamics in the bypassed arteries and suppress intimal hyperplasia along the host artery floor

The development of distal end-to-side anastomotic intimal hyperplasia (IH) has been attributed to the flow disturbance and abnormal wall shear stress (WSS) distribution there. The geometry of the bypass has a strong influence on the flow pattern and WSS distribution. Using a canine model of end-to-side anastomosis, a 45 degrees S-type bypass was compared with 60 degrees , 45 degrees and 30 degrees conventional bypasses in the term of IH along the host artery floor. Numerical blood flow simulations were also carried out to characterize the flow patterns at the distal parts of the bypassed arteries for the 4 models. The results showed that the averaged intima thicknesses of the host artery floors for the 4 bypass models were 119.50+/-10.30 microm (60 degrees ), 65.56+/-6.53 microm (45 degrees ), 45.26+/-5.99 microm (30 degrees ) and 47.64+/-4.85 microm (S-type), respectively, vs. 9.81+/-1.88 microm in the control group (without bypass surgery). Compared with the control group, neointima thickness in all 4 bypass models was significantly increased, but the neointima thickness of the 45 degrees S-type bypass was apparently much better than its 45 degrees conventional counterpart, and was as good as the 30 degrees conventional bypass. The numerical simulation revealed an apparent swirling flow pattern in the S-type bypass, which was very different than the flow patterns in the 3 conventional bypass models. This swirling flow altered the overall flow pattern in the distal part of the bypassed artery and eliminated the low WSS zone along the host artery floor. The improvement in the term of IH for the S-type bypass is most likely due to the alteration of the overall flow pattern and WSS distribution by the geometrical configuration of the S-type bypass.     

Simulation of particle-hemodynamics in a partially occluded artery segment with implications to the initiation of microemboli and secondary stenoses.

Computational results of laminar incompressible blood-particle flow analyses in an axisymmetric artery segment with a smooth local area constriction of 75 percent have been presented. The flow input waveform was sinusoidal with a nonzero average. The non-Newtonian behavior of blood was simulated with a modified Quemada model, platelet concentrations were calculated with a drift-flux model, and monocyte trajectories were described and compared for both Newtonian and Quemada rheologies. Indicators of "disturbed flow" included the time-averaged wall shear stress (WSS), the oscillatory shear index (OSI), and the wall shear stress gradient (WSSG). Implications of the vortical flow patterns behind the primary stenosis to the formation of microemboli and downstream stenoses are as follows. Elevated platelet concentrations due to accumulation in recirculation zones mixed with thrombin and ADP complexes assumed to be released upstream in high wall shear stress regions, could form microemboli, which are convected downstream. Distinct near-wall vortices causing a local increase in the WSSG and OSI as well as blood-particle entrainment with possible wall deposition, indicate sites susceptible to the onset of an additional stenosis proximal to the initial geometric disturbance.     

Is there a haemodynamic advantage associated with cuffed arterial anastomoses?

The development of intimal hyperplasia at arterial bypass graft anastomoses is a major factor responsible for graft failure. A revised surgical technique, involving the incorporation of a small section of vein (vein cuff) into the distal anastomosis of PTFE grafts, results in an altered distribution of intimal hyperplasia and improved graft patency rates, especially for below-knee grafts. Numerical simulations have been conducted under physiological conditions to identify the flow behaviour in a typical cuffed bypass model and to determine whether the improved performance of the cuffed system can be accounted for by haemodynamic factors. The flow patterns at the cuffed anastomosis are significantly different to those at the conventional end-to-side anastomosis. In the former case, the flow is characterised by an expansive, low momentum recirculation within the cuff. Separation occurs at the graft heel, and at the cuff toe as the blood enters the recipient artery. Wall shear stresses in the vicinity of the cuff heel are low, but high shear stresses and large spatial gradients in the shearing force act on the artery floor during systole. In contrast, a less disturbed flow prevails and the floor shear stress distribution is less adverse in the conventional model. In conclusion, aspects of the anastomotic haemodynamics are worsened when the cuff is employed. The benefits associated with the cuffed grafts may be related primarily to the presence of venous material at the anastomosis. Therefore, caution is advised with regard to the use of PTFE grafts, pre-shaped to resemble a cuffed geometry.     

Numerical simulations of pulsatile flow in an end-to-side anastomosis model

A potential interaction between the local hemodynamics and the artery wall response has been suggested for vascular graft failure by intimal hyperplasia (IH). Among the various hemodynamic factors, wall shear stress has been implicated as the primary factor responsible for the development of IH. In order to explore the role of hemodynamics in the formation of IH in end-to-side anastomosis, computational fluid dynamics is employed. To validate the numerical simulations, comparisons with existing experimental data are performed for both steady and pulsatile flows. Generally, good agreement is observed with the velocity profiles whereas some discrepancies are found in wall shear stress (WSS) distributions. Using the same end-to-side anastomosis geometry, numerical simulations are extended using a femoral artery waveform to identify the possible role of unsteady hemodynamics. In the current simulations, Carreau-Yasuda model is used to account for the non-Newtonian nature of blood. Computations indicated a disturbed flow field at the artery-graft junction leading to locally elevated shear stresses on the vascular wall. Furthermore, the shear stress distribution followed the same behavior with oscillating magnitude over the entire flow cycle. Thus, distal IH observed in end-to-side artery-graft models may be caused by the fluctuations in WSS's along the wall.     

Non-Newtonian effects of blood flow on hemodynamics in distal vascular graft anastomoses

Non-Newtonian fluid flow in a stenosed coronary bypass is investigated numerically using the Carreau-Yasuda model for the shear thinning behavior of the blood. End-to-side coronary bypass anastomosis is considered in a simplified model geometry where the host coronary artery has a 75% severity stenosis. Different locations of the bypass graft to the stenosis and different flow rates in the graft and in the host artery are studied. Particular attention is given to the non-Newtonian effect of the blood on the primary and secondary flow patterns in the host coronary artery and the wall shear stress (WSS) distribution there. Interaction between the jet flow from the stenosed artery and the flow from the graft is simulated by solving the three-dimensional Navier-Stokes equation coupled with the non-Newtonian constitutive model. Results for the non-Newtonian flow, the Newtonian flow and the rescaled Newtonian flow are presented. Significant differences in axial velocity profiles, secondary flow streamlines and WSS between the non-Newtonian and Newtonian fluid flows are revealed. However, reasonable agreement between the non-Newtonian and the rescaled Newtonian flows is found. Results from this study support the view that the residual flow in a partially occluded coronary artery interacts with flow in the bypass graft and may have significant hemodynamic effects in the host vessel downstream of the graft. Non-Newtonian property of the blood alters the flow pattern and WSS distribution and is an important factor to be considered in simulating hemodynamic effects of blood flow in arterial bypass grafts.     

Effects of vessel compliance on flow pattern in porcine epicardial right coronary arterial tree

The compliance of the vessel wall affects hemodynamic parameters which may alter the permeability of the vessel wall. Based on experimental measurements, the present study established a finite element (FE) model in the proximal elastic vessel segments of epicardial right coronary arterial (RCA) tree obtained from computed tomography. The motion of elastic vessel wall was measured by an impedance catheter and the inlet boundary condition was measured by an ultrasound flow probe. The Galerkin FE method was used to solve the Navier–Stokes and Continuity equations, where the convective term in the Navier–Stokes equation was changed in the arbitrary Lagrangian–Eulerian (ALE) framework to incorporate the motion due to vessel compliance. Various hemodynamic parameters (e.g., wall shear stress—WSS, WSS spatial gradient—WSSG, oscillatory shear index—OSI) were analyzed in the model. The motion due to vessel compliance affects the time-averaged WSSG more strongly than WSS at bifurcations. The decrease of WSSG at flow divider in elastic bifurcations, as compared to rigid bifurcations, implies that the vessel compliance decreases the permeability of vessel wall and may be atheroprotective. The model can be used to predict coronary flow pattern in subject-specific anatomy as determined by noninvasive imaging.     

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

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

Hemodynamics and wall mechanics in human carotid bifurcation and its consequences for atherogenesis: investigation of inter-individual variation

Finite element simulations of fluid-solid interactions were used to investigate inter-individual variations in flow dynamics and wall mechanics at the carotid artery bifurcation, and its effects on atherogenesis, in three healthy humans (normal volunteers: NV1, NV2, NV4). Subject-specific calculations were based on MR images of structural anatomy and ultrasound measurements of flow at domain boundaries. For all subjects, the largest contiguous region of low wall shear stress (WSS) occurred at the carotid bulb, WSS was high (6-10 Pa) at the apex, and a small localized region of WSS > 10 Pa occurred close to the inner wall of the external carotid artery (ECA). NV2 and NV4 had a "spot" of low WSS distal to the bifurcation at the inner wall of the ECA. Low WSS patches in the common carotid artery (CCA) were contiguous with the carotid bulb low WSS region in NV1 and NV2, but not in NV4. In all three subjects, areas of high oscillatory shear index (OSI) were confined to regions of low WSS. Only NV4 exhibited high levels of OSI on the external adjoining wall of the ECA and CCA. For all subjects, the maximum wall shear stress temporal gradient (WSSTG) was highest at the flow divider (reaching 1,000 Pa/s), exceeding 300 Pa/s at the walls connecting the ECA and CCA, but remaining below 250 Pa/s outside of the ECA. In all subjects, (maximum principle) cyclic strain (CS) was greatest at the apex (NV1: 14%; NV2: 11%; NV4: 6%), and a second high CS region occurred at the ECA-CCA adjoining wall (NV1: 11%, NV2: 9%, NV4: 5%). Wall deformability was included in one simulation (NV2) to verify that it had little influence on the parameters studied. Location and magnitude of low WSS were similar, except for the apex (differences of up to 25%). Wall distensibility also influenced OSI, doubling it in most of the CCA, separating the single high OSI region of the carotid bulb into two smaller regions, and shrinking the ECA internal and external walls' high OSI regions. These observations provide further evidence that significant intra-subject variability exists in those factors thought to impact atherosclerosis.     

PIV-validated numerical modeling of pulsatile flows in distal coronary end-to-side anastomoses

This study employed particle image velocimetry (PIV) to validate a numerical model in a complementary approach to quantify hemodynamic factors in distal coronary anastomoses and to gain more insights on their relationship with anastomotic geometry. Instantaneous flow fields and wall shear stresses (WSS) were obtained from PIV measurement in a modified life-size silastic anastomosis model adapted from a conventional geometry by incorporating a smooth graft-artery transition. The results were compared with those predicted by a concurrent numerical model. The numerical method was then used to calculate cycle-averaged WSS (WSS(cyc)) and spatial wall shear stress gradient (SWSSG), two critical hemodynamic factors in the pathogenesis of intimal thickening (IT), to compare the conventional and modified geometries. Excellent qualitative agreement and satisfactory quantitative agreement with averaged normalized error in WSS between 0.8% and 8.9% were achieved between the PIV experiment and numerical model. Compared to the conventional geometry, the modified geometry produces a more uniform WSS(cyc) distribution eliminating both high and low WSS(cyc) around the toe, critical in avoiding IT. Peak SWSSG on the artery floor of the modified model is less than one-half that in the conventional case, and high SWSSG at the toe is eliminated. The validated numerical model is useful for modeling unsteady coronary anastomotic flows and elucidating the significance of geometry regulated hemodynamics. The results suggest the clinical relevance of constructing smooth graft-artery transition in distal coronary anastomoses to improve their hemodynamic performance.     

Sequential venous anastomosis design to enhance patency of arterio-venous grafts for hemodialysis

Arterio-venous grafts (AVGs), the second best option as long-term vascular access for hemodialysis, face major issues of stenosis mainly due to development of intimal hyperplasia at the venous anastomosis which is linked to unfavorable hemodynamic conditions. We have investigated computationally the utility of a coupled sequential venous anastomotic design to replace conventional end-to-side (ETS) venous anastomosis, in order to improve the hemodynamic environment and consequently enhance the patency of AVGs. Two complete vascular access models with the conventional and the proposed venous anastomosis configurations were constructed. Three-dimensional, pulsatile blood flow through the models was simulated, and wall shear stress (WSS)-based hemodynamic parameters were calculated and compared between the two models. Simulation results demonstrated that the proposed anastomotic design provides: (i) a more uniform and smooth flow at the ETS anastomosis, without flow impingement and stagnation point on the artery bed and vortex formation in the heel region of the ETS anastomosis; (ii) more uniform distribution of WSS and substantially lower WSS gradients on the venous wall; and (iii) a spare route for the blood flow to the vein, to avoid re-operation in case of stenosis. The distinctive hemodynamic advantages observed in the proposed anastomotic design can enhance the patency of AVGs.     

Flow and wall shear stress in end-to-side and side-to-side anastomosis of venous coronary artery bypass grafts

Purpose  

Coronary artery bypass graft (CABG) surgery represents the standard treatment of advanced coronary artery disease. Two major types of anastomosis exist to connect the graft to the coronary artery, i.e., by using an end-to-side or a side-to-side anastomosis. There is still controversy because of the differences in the patency rates of the two types of anastomosis. The purpose of this paper is to non-invasively quantify hemodynamic parameters, such as mass flow and wall shear stress (WSS), in end-to-side and side-to-side anastomoses of patients with CABG using computational fluid dynamics (CFD).     

Curvature effect on hemodynamic conditions at the inner bend of the carotid siphon and its relation to aneurysm formation

Although high-impact hemodynamic forces are thought to lead to cerebral aneurysmal change, little is known about the aneurysm formation on the inner aspect of vascular bends such as the internal carotid artery (ICA) siphon where wall shear stress (WSS) is expected to be low. This study evaluates the effect of vessel curvature and hemodynamics on aneurysm formation along the inner carotid siphon. Catheter 3D-rotational angiographic volumes of 35 ICA (10 aneurysms, 25 controls) were evaluated in 3D for radius of curvature and peak curvature of the siphon bend, followed by univariate statistical analysis. Computational fluid dynamic (CFD) simulations were performed on patient-derived models after aneurysm removal and on synthetic variants of increasing curvature. Peak focal siphon curvature was significantly higher in aneurysm bearing ICAs (0.36±0.045 vs. 0.30±0.048 mm⁻¹, p=0.003), with no difference in global radius of curvature (p=0.36). In CFD simulations, increasing parametric curvature tightness (from 5 to 3 mm radius) resulted in dramatic increase of WSS and WSS gradient magnitude (WSSG) on the inner wall of the bend. In patient-derived data, the location of aneurysms coincided with regions of low WSS (<4 Pa) flanked by high WSS and WSSG peaks. WSS peaks correlated with the aneurysm neck. In contrast, control siphon bends displayed low, almost constant, WSS and WSSG profiles with little spatial variation. High bend curvature induces dynamically fluctuating high proximal WSS and WSSG followed by regions of flow stasis and recirculation, leading to local conditions known to induce destructive vessel wall remodeling and aneurysmal initiation.