Validation of numerical flow simulations against in vitro phantom measurements in different type B aortic dissection scenarios

An aortic dissection (AD) is a serious condition defined by the splitting of the arterial wall, thus generating a secondary lumen [the false lumen (FL)]. Its management, treatment and follow-up are clinical challenges due to the progressive aortic dilatation and potentially severe complications during follow-up. It is well known that the direction and rate of dilatation of the artery wall depend on haemodynamic parameters such as the local velocity profiles, intra-luminal pressures and resultant wall stresses. These factors act on the FL and true lumen, triggering remodelling and clinical worsening. In this study, we aimed to validate a computational fluid dynamic (CFD) tool for the haemodynamic characterisation of chronic (type B) ADs. We validated the numerical results, for several dissection geometries, with experimental data obtained from a previous in vitro study performed on idealised dissected physical models. We found a good correlation between CFD simulations and experimental measurements as long as the tear size was large enough so that the effect of the wall compliance was negligible.     

Computational modeling of the fluid flow in type B aortic dissection using a modified finite element embedded formulation

Biomechanics and Modeling in Mechanobiology - This work explores the use of an embedded computational fluid dynamics method to study the type B aortic dissection. The use of the proposed technique...     

Changes in inflammatory response after endovascular treatment for type B aortic dissection

This present study aims to investigate the changes in the inflammatory markers after elective endovascular treatment of Type B aortic dissection with aneurysm, as related to different anatomical features of the dissection flap in the paravisceral perfusion. Consecutive patients with type B aortic dissections with elective endovascular stent graft repair were recruited and categorized into different groups. Serial plasma levels of cytokines (Interleukin-1β, -6, -8, -10, TNF-α), chemokines (MCP-1), and serum creatinine were monitored at pre-, peri- and post-operative stages. The length of stent graft employed in each surgery was retrieved and correlated with the change of all studied biochemical parameters. A control group of aortic dissected patients with conventional medication management was recruited for comparing the baseline biochemical parameters. In total, 22 endovascular treated and 16 aortic dissected patients with surveillance were recruited. The endovascular treated patients had comparable baseline levels as the non-surgical patients. There was no immediate or thirty day-mortality, and none of the surgical patients developed post-operative mesenteric ischaemia or clinically significant renal impairment. All surgical patients had detectable pro-inflammatory mediators, but none of the them showed any statistical significant surge in the peri-operative period except IL-1β and IL-6. Similar results were obtained when categorized into different groups. IL-1β and IL-6 showed maximal levels within hours of the endovascular procedure (range, 3.93 to 27.3 higher than baseline; p?=?0.001), but returned to baseline 1 day post-operatively. The change of IL-1β and IL-6 at the stent graft deployment was statistically greater in longer stent graft (p>0.05). No significant changes were observed in the serum creatinine levels. In conclusion, elective endovascular repair of type B aortic dissection associated with insignificant changes in inflammatory mediators and creatinine. All levels fell toward basal levels post-operatively suggesting that thoracic endovascular aortic repair is rather less aggressive with insignificant inflammatory modulation.     

Hybrid thoracic stent graft repair of a complex type B aortic dissection in a patient who presented three weeks after repair of a type a aortic dissection

Long-term management after repair of a type A aortic dissection includes aggressive medical therapy and routine surveillance with serial imaging to ensure thrombosis of the false lumen. Retained patency of the false lumen can lead to either the development of a false lumen aneurysm with a subsequent rupture or extension of dissection. Typically such events occur late, usually months after repair, and are treated with either a conventional one-stage open thoracoabdominal repair or a two-stage "elephant trunk" procedure. However, most patients who undergo such procedures experience major complications and the procedure-related mortality rate is high. We present a unique case of a 61-year-old woman who presented with a ruptured type B aortic dissection 3 weeks after repair of a type A aortic dissection. She underwent an emergent thoracotomy and primary repair of the ruptured aorta followed by concomitant arch debranching and thoracic stent graft placement. Simultaneous surgical debranching with a median sternotomy and endovascular repair with stent grafts is an attractive hybrid approach in patients who present with an acute rupture of a false lumen aneurysm soon after initial repair of an aortic dissection, a situation in which a conventional repair is not feasible. This report emphasizes that hybrid thoracic stent graft repair should be considered for such high-risk patients in the near future as it offers them relatively lower morbidity and mortality compared with what is seen with conventional repairs.     

Intermediate fenestrations reduce flow reversal in a silicone model of Stanford Type B aortic dissection

Pulsatile, three-dimensional hemodynamic forces influence thrombosis, and may dictate progression of aortic dissection. Intimal flap fenestration and blood pressure are clinically relevant variables in this pathology, yet their effects on dissection hemodynamics are poorly understood. The goal of this study was to characterize these effects on flow in dissection models to better guide interventions to prevent aneurysm formation and false lumen flow. Silicone models of aortic dissection with mobile intimal flap were fabricated based on patient images and installed in a flow loop with pulsatile flow. Flow fields were acquired via 4-dimensional flow MRI, allowing for quantification and visualization of relevant fluid mechanics. Pulsatile vortices and jet-like structures were observed at fenestrations immediately past the proximal entry tear. False lumen flow reversal was significantly reduced with the addition of fenestrations, from 19.2 ± 3.3% in two-tear dissections to 4.67 ± 1.5% and 4.87 ± 1.7% with each subsequent fenestration. In contrast, increasing pressure did not cause appreciable differences in flow rates, flow reversal, and vortex formation. Increasing the number of intermediate tears decreased flow reversal as compared to two-tear dissection, which may prevent false lumen thrombosis, promoting persistent false lumen flow. Vortices were noted to result from transluminal fluid motion at distal tear sites, which may lead to degeneration of the opposing wall. Increasing pressure did not affect measured flow patterns, but may contribute to stress concentrations in the aortic wall. The functional and anatomic assessment of disease with 4D MRI may aid in stratifying patient risk in this population.     

Patient-specific simulation of stent-graft deployment in type B aortic dissection: model development and validation

Thoracic endovascular aortic repair (TEVAR) has been accepted as the mainstream treatment for type B aortic dissection, but post-TEVAR biomechanical-related complications are still a major drawback. Unfortunately, the stent-graft (SG) configuration after implantation and biomechanical interactions between the SG and local aorta are usually unknown prior to a TEVAR procedure. The ability to obtain such information via personalised computational simulation would greatly assist clinicians in pre-surgical planning. In this study, a virtual SG deployment simulation framework was developed for the treatment for a complicated aortic dissection case. It incorporates patient-specific anatomical information based on pre-TEVAR CT angiographic images, details of the SG design and the mechanical properties of the stent wire, graft and dissected aorta. Hyperelastic material parameters for the aortic wall were determined based on uniaxial tensile testing performed on aortic tissue samples taken from type B aortic dissection patients. Pre-stress conditions of the aortic wall and the action of blood pressure were also accounted for. The simulated post-TEVAR configuration was compared with follow-up CT scans, demonstrating good agreement with mean deviations of 5.8% in local open area and 4.6 mm in stent strut position. Deployment of the SG increased the maximum principal stress by 24.30 kPa in the narrowed true lumen but reduced the stress by 31.38 kPa in the entry tear region where there was an aneurysmal expansion. Comparisons of simulation results with different levels of model complexity suggested that pre-stress of the aortic wall and blood pressure inside the SG should be included in order to accurately predict the deformation of the deployed SG.

     

The effect of inlet flow profile and nozzle diameter on drug delivery to the maxillary sinus

In this paper, the effect of the turbulence and swirling of the inlet flow and the diameter of the nozzle on the flow characteristics and the particles' transport/deposition patterns in a realistic combination of the nasal cavity (NC) and the maxillary sinus (MS) were examined. A computational fluid dynamics (CFD) model was developed in ANSYS® Fluent using a hybrid Reynolds averaged Navier–Stokes–large-eddy simulation algorithm. For the validation of the CFD model, the pressure distribution in the NC was compared with the experimental data available in the literature. An Eulerian–Lagrangian approach was employed for the prediction of the particle trajectories using a discrete phase model. Different inlet flow conditions were investigated, with turbulence intensities of 0.15 and 0.3, and swirl numbers of 0.6 and 0.9 applied to the inlet flow at a flow rate of 7 L/min. Monodispersed particles with a diameter of 5 µm were released into the nostril for various nozzle diameters. The results demonstrate that the nasal valve plays a key role in nasal resistance, which damps the turbulence and swirl intensities of the inlet flow. Moreover, it was found that the effect of turbulence at the inlet of the NC on drug delivery to the MS is negligible. It was also demonstrated that increasing the flow swirl at the inlet and decreasing the nozzle diameter improves the total particle deposition more than threefold due to the generation of the centrifugal force, which acts on the particles in the nostril and vestibule. The results also suggest that the drug delivery efficiency to the MS can be increased by using a swirling flow with a moderate swirl number of 0.6. It was found that decreasing the nozzle diameter can increase drug delivery to the proximity of the ostium in the middle meatus by more than 45%, which subsequently increases the drug delivery to the MS. The results can help engineers design a nebulizer to improve the efficiency of drug delivery to the maxillary sinuses.

     

A computational model for false lumen thrombosis in type B aortic dissection following thoracic endovascular repair

Thoracic endovascular repair (TEVAR) has recently been established as the preferred treatment option for complicated type B dissection. This procedure involves covering the primary entry tear to stimulate aortic remodelling and promote false lumen thrombosis thereby restoring true lumen flow. However, complications associated with incomplete false lumen thrombosis, such as aortic dilatation and stent graft induced new entry tears, can arise after TEVAR. This study presents the application and validation of a recently developed mathematical model for patient-specific prediction of thrombus formation and growth under physiologically realistic flow conditions. The model predicts thrombosis through the evaluation of shear rates, fluid residence time and platelet distribution, based on convection-diffusion-reaction transport equations. The model was applied to 3 type B aortic dissection patients: two TEVAR cases showing complete and incomplete false lumen thrombosis respectively, and one medically treated dissection with no signs of thrombosis. Predicted thrombus growth over time was validated against follow-up CT scans, showing good agreement with in vivo data in all cases with a maximum difference between predicted and measured false lumen reduction below 8%. Our results demonstrate that TEVAR-induced thrombus formation in type B aortic dissection can be predicted based on patient-specific anatomy and physiologically realistic boundary conditions. Our model can be used to identify anatomical or stent graft related factors that are associated with incomplete false lumen thrombosis following TEVAR, which may help clinicians develop personalised treatment plans for dissection patients in the future.     

The effect of body weight on the degree of blood velocity profile skewness in the aortic annulus in domestic pigs

We investigated the blood velocity profile in the aortic annulus (AA) in two groups of domestic pigs using epicardial Doppler echocardiography. The velocity profile skewness in terms of max/mean TVI (the ratio of maximal to cross-sectional mean time-velocity integral along the diameter) was 1.107 +/- 0.01 in the small pigs (n = 10; body weight: 24.6 +/- 0.8 kg) and 1.216 +/- 0.026 in the large pigs (n = 8; body weight: 50.6 +/- 2.5 kg) (P = 0.002). The velocity profile in the AA is more skewed in large animals than in small animals and the skewness in the larger animals is similar to that in normal adult humans. This study shows the importance of choosing animals of sufficient size if flow method investigations are to be performed. This is particularly important for ultrasound Doppler investigations based on a limited sample of velocities across the flow channel.     

Seasonal incidence of hospital admissions for Stanford type A aortic dissection

The objective of this study was to test the hypothesis that there is seasonal variation in the incidence of Stanford type A aortic dissection (SA-AoD) among patients admitted to our cardiovascular surgical service. A sinusoidal logistic regression model was used to analyze event data for 6081 calendar days. A cyclic peak risk for SA-AoD was observed for calendar day 304 (p?=?0.019). The odds ratios for the 3- and 6-month window surrounding this peak were 1.6 (p?=?0.054) and 1.7 (p?=?0.0040), respectively. Our results suggest than a seasonal variation exists in the incidence of SA-AoD.     

Numerical simulation of two-phase non-Newtonian blood flow with fluid-structure interaction in aortic dissection

The behavior of blood cells and vessel compliance significantly influence hemodynamic parameters, which are closely related to the development of aortic dissection. Here the two-phase non-Newtonian model and the fluid-structure interaction (FSI) method are coupled to simulate blood flow in a patient-specific dissected aorta. Moreover, three-element Windkessel model is applied to reproduce physiological pressure waves. Important hemodynamic indicators, such as the spatial distribution of red blood cells (RBCs) and vessel wall displacement, which greatly influence the hemodynamic characteristics are analyzed. Results show that the proximal false lumen near the entry tear appears to be a vortex zone with a relatively lower volume fraction of RBCs, a low time-averaged wall shear stress (TAWSS) and a high oscillatory shear index (OSI), providing a suitable physical environment for the formation of atherosclerosis. The highest TAWSS is located in the narrow area of the distal true lumen which might cause further dilation. TAWSS distributions in the FSI model and the rigid wall model show similar trend, while there is a significant difference for the OSI distributions. We suggest that an integrated model is essential to simulate blood flow in a more realistic physiological environment with the ultimate aim of guiding clinical treatment.     

Morphological parameters affecting false lumen thrombosis following type B aortic dissection: a systematic study based on simulations of idealized models

Type B aortic dissection (TBAD) carries a high risk of complications, particularly with a partially thrombosed or patent false lumen (FL). Therefore, uncovering the risk factors leading to FL thrombosis is crucial to identify high-risk patients. Although studies have shown that morphological parameters of the dissected aorta are related to FL thrombosis, often conflicting results have been reported. We show that recent models of thrombus evolution in combination with sensitivity analysis methods can provide valuable insights into how combinations of morphological parameters affect the prospect of FL thrombosis. Based on clinical data, an idealized geometry of a TBAD is generated and parameterized. After implementing the thrombus model in computational fluid dynamics simulations, a global sensitivity analysis for selected morphological parameters is performed. We then introduce dimensionless morphological parameters to scale the results to individual patients. The sensitivity analysis demonstrates that the most sensitive parameters influencing FL thrombosis are the FL diameter and the size and location of intimal tears. A higher risk of partial thrombosis is observed when the FL diameter is larger than the true lumen diameter. Reducing the ratio of the distal to proximal tear size increases the risk of FL patency. In summary, these parameters play a dominant role in classifying morphologies into patent, partially thrombosed, and fully thrombosed FL. In this study, we point out the predictive role of morphological parameters for FL thrombosis in TBAD and show that the results are in good agreement with available clinical studies.

     

Effect of loading conditions on peak aortic flow velocity and its maximal acceleration.

Aortic flow measurement with Doppler echocardiography has become a non-invasive technique in clinical practice. In the present animal study, we evaluated the flow-derived parameters such as peak velocity (PV) and its maximal acceleration (MA) as indices of ventricular contractility independent of the loading status. Eight pentobarbital-anesthetized cats were maintained with artificial ventilation. The chest was opened to place an electromagnetic flow probe around the ascending aorta for recording pulsatile aortic flow. PV and MA were measured from the flow tracing and on-line electronic differentiation. Intravenous infusions of dobutamine (DT), angiotensin II (AII) and dextran (DN) were used to alter the cardiac inotropism, afterload and preload, respectively. At a steady state (approximately 5 min after infusion), DT increased the PV from 56 +/- 9 to 78 +/- 14 cm/sec (p less than 0.05) and MA from 1302 +/- 108 to 1699 +/- 117 cm/sec2 (p less than 0.05). In response to AII infusion, PV was slightly reduced (60 +/- 7 to 55 +/- 6 cm/sec, p less than 0.05) while MA was also reduced mildly but significantly (1219 +/- 109 to 1099 +/- 109 cm/sec2, p less than 0.05). Dextran infusion produced a marked increase in PV (48 +/- 7 to 82 +/- 13 cm/sec, p less than 0.05) while the increase was slightly less for MA (1089 +/- 95 to 1604 +/- 109 cm/sec2). The results indicated that inotropic stimulation markedly increased both PV and MA. PV and MA responded slightly but significantly to afterload alterations. (8.3% vs 9.8%, respectively). Both PV and MA increased markedly to the preload increment.(ABSTRACT TRUNCATED AT 250 WORDS)     

The strength of the aortic media and its role in the propagation of aortic dissection

The elastic properties of the thoracic aorta are well known, but this is the first study of the inherent strength of the tunica media. The latter is crucial to understand how dissecting aneurysms occur. Pressure-volume (P-V) measurements were recorded as a dilute suspension of India ink was infused into the tunica media using a constant flow pump (0.21 or 0.88 ml min-1) attached to a 20 G needle inserted into the media. Tests done on 31 opened pig upper descending thoracic aortas showed the peak pressure to tear the media averaged 77.2 +/- 1.5 kPa (579 mm Hg). The initial slope of the P-V curve revealed the average distensibility of the media of 3.02 +/- 0.28 (MPa)-1. The work per unit area of tissue required to propagate a tear in the aorta was 15.9 +/- 0.9 mJ cm-2. These values were independent of the tear depth at the 95% confidence interval.     

The role of D-dimers in the diagnosis of acute aortic dissection

Acute aortic dissection (AAD) is a life threatening cardiovascular medical emergency with a poor prognosis. To explore the utility of D-dimers (DD) in the diagnosis of AAD, we performed a prospective study and conducted a meta-analysis of previous studies. 368 suspected patients were enrolled, including AAD n = 89, PE n = 12, AMI n = 167, normal controls n = 100. All patients had a DD test immediately after admission. We then performed a comprehensive computer search to identify studies investigating using DD as a screening tool for AAD. Finally, we pooled these data to estimate sensitivity, specificity, positive and negative likelihood ratios (LRs) by using DerSimonian–Laird random-effects models. The DD concentrations in the AAD group were significantly higher than those in the AMI and normal control groups. However, the DD level of 500 ng/ml had a poor sensitivity of 51.7 % and specificity of 89.2 % in the diagnosis of AAD. Subgroup analyses found that DD only showed a well discriminative ability of distinguishing AAD patients from normal controls (specificity and positive LR was 97 % and 17.2, respectively). The pooled sensitivity, specificity, positive and negative LR in our meta-analysis was 89, 68 %, 2.71, 0.07, respectively. In conclusion, our results suggest that plasma DD levels cannot add to the certainty of AAD diagnosis and it is not a good biomarker for AAD. In the future, prospective research on patients from many parts of the world is warranted to validate our findings. In addition, different controls, methods of plasma DD assays and other factors should be considered.     

Pulsatile flow in fusiform models of abdoiminal aortic aneurysms: flow fields, velocity patterns and flow-induced wall stresses

As one important step in the investigation of the mechanical factors that lead to rupture of abdominal aortic aneurysms, flow fields and flow-induced wall stress distributions have been investigated in model aneurysms under pulsatile flow conditions simulating the in vivo aorta at rest. Vortex pattern emergence and evolution were evaluated, and conditions for flow stability were delineated. Systolic flow was found to be forward-directed throughout the bulge in all the models, regardless of size. Vortices appeared in the bulge initially during deceleration from systole, then expanded during the retrograde flow phase. The complexity of the vortex field depended strongly on bulge diameter In every model, the maximum shear stress occurred at peak systole at the distal bulge end, with the greatest shear stress developing in a model corresponding to a 4.3 cm AAA in vivo. Although the smallest models exhibited stable flow throughout the cycle, flow in the larger models became increasingly unstable as bulge size increased, with strong amplification of instability in the distal half of the bulge. These data suggest that larger aneurysms in vivo may be subject to more frequent and intense turbulence than smaller aneurysms. Concomitantly, increased turbulence may contribute significantly to wall stress magnitude and thereby to risk of rupture.     

Fluid–structure interaction analysis of turbulent pulsatile flow within a layered aortic wall as related to aortic dissection

Turbulent pulsatile flow and wall mechanics were studied numerically in an axisymmetric three-layered wall model of a descending aorta. The transport equations were solved using the finite element formulation based on the Galerkin method of weighted residuals. A fully-coupled fluid–structure interaction (FSI) analysis was utilized in this investigation. We calculated Von Mises wall stress, streamlines and fluid pressure contours. The findings of this study show that peak wall stress and maximum shear stress are highest in the media layer. The difference in the elastic properties of contiguous layers of the wall of the aorta probably determines the occurrence of dissection in the media layer. Moreover, the presence of aortic intramural hematoma is found to have a significant effect on the peak wall stress acting on the inner layer.     

Spatial velocity profile in mouse embryonic aorta and Doppler-derived volumetric flow: a preliminary model

Characterizing embryonic circulatory physiology requires accurate cardiac output and flow data. Despite recent applications of high-frequency ultrasound Doppler to the study of embryonic circulation, current Doppler analysis of volumetric flow is relatively crude. To improve Doppler derivation of volumetric flow, we sought a preliminary model of the spatial velocity profile in the mouse embryonic dorsal aorta using ultrasound biomicroscopy (UBM)-Doppler data. Embryonic hematocrit is 0.05-0.10 so rheologic properties must be insignificant. Low Reynolds numbers (<500) and Womersley parameters (<0.76) suggest laminar flow. UBM demonstrated a circular dorsal aortic cross section with no significant tapering. Low Dean numbers (<100) suggest the presence of minimal skewing of the spatial velocity profile. The inlet length allows for fully developed flow. There is no apparent aortic wall pulsatility. Extrapolation of prior studies to these vessel diameters (300-350 microm) and flow velocities (~50-200 mm/s) suggests parabolic spatial velocity profiles. Therefore, mouse embryonic dorsal aortic blood flow may correspond to Poiseuille flow in a straight rigid tube with parabolic spatial velocity profiles. As a first approximation, these results are an important step toward precise in utero ultrasound characterization of blood flow within the developing mammalian circulation.