Biomechanical and morphometric properties of the arterial wall referenced to the zero-stress state in experimental diabetes

Morphometric and passive biomechanical properties were studied in isolated segments of the thoracic and abdominal aorta, left common carotid artery, left femoral artery and the left pulmonary artery in 20 non-diabetic and 28 streptozotocin (STZ)-induced diabetic rats. The diabetic and non-diabetic rats were divided into groups living 1, 4, 8, and 12 weeks after the induction of diabetes (n = 7 for each diabetic group) or sham injection (n = 5 for each group). The mechanical test was performed as a distension experiment where the proximal end of the arterial segment was connected via a tube to the container used for applying pressures to the segment and the distal end was left free. The vessel diameter and length were obtained from digitized images of the arterial segments at pre-selected pressures and at no-load and zero-stress states. Circumferential and longitudinal stresses (force per area) and strains (deformation) were computed from the length, diameter and pressure data and from the zero-stress state data. The zero-stress state was obtained by cutting vessel rings radially causing the rings to open up into a sector. Diabetes was associated with pronounced morphometric changes, e.g., wall thickness. With respect to the biomechanical data, the opening angle increased and reached a plateau in 4 weeks after which it decreased again (p < 0.05). The opening angle was smallest in the thoracic aorta and largest in the pulmonary artery. Furthermore, it was found that the circumferential stiffness of the arteries studied increased with the duration of diabetes. In the longitudinal direction significant differences were found 8 weeks after injection of STZ in all arteries except the pulmonary artery. In the 12 weeks group, the femoral artery was stiffest in the circumferential direction whereas the thoracic aorta was stiffest in the longitudinal direction. The accumulated serum glucose level correlated with the arterial wall thickness and elastic modulus (correlation coefficient between 0.56 and 0.81).     

Biomechanical and morphological properties in rat large intestine

Intestinal stress-strain distributions are important determinants of intestinal function and are determined by the mechanical properties of the intestinal wall, the physiological loading conditions and the zero-stress state of the intestine. In this study the distribution of morphometric measures, residual circumferential strains and stress-strain relationships along the rat large intestine were determined in vitro. Segments from four parts of the large intestine were excised, closed at both ends, and inflated with pressures up to 2kPa. The outer diameter and length were measured. The zero-stress state was obtained by cutting rings of large intestine radially. The geometric configuration at the zero-stress state is of fundamental importance because it is the basic state with respect to which the physical stresses and strains are defined. The outer and inner circumferences, wall thickness and opening angle were measured from digitised images. Subsequently, residual strain and stress-strain distributions were calculated. The wall thickness and wall thickness-to-circumference ratio increased in the distal direction. The opening angle varied between approximately 40 and approximately 125 degrees with the highest values in the beginning of proximal colon (F=1.739, P<0.05). The residual strain at the inner surface was negative indicating that the mucosa-submucosal layers of the large intestine in no-load state are in compression. The four segments showed stress-strain distributions that were exponential. All segments were stiffer in longitudinal direction than in the circumferential direction (P<0.05). The transverse colon seemed stiffest both in the circumferential and longitudinal directions. In conclusion, significant variations were found in morphometric and biomechanical properties along the large intestine. The circumferential residual strains and passive elastic properties must be taken into account in studies of physiological problems in which the stress and strain are important, e.g. large intestinal bolus transport function.     

Changes in the rheological properties of blood vessel tissue remodeling in the course of development of diabetes.

Rheological properties of blood vessels are expected to change in disease process if the structure of the vessel wall changes. This is illustrated in diabetes, which can be induced in rat by a single injection of Streptozocin. One of the rheological properties of the blood vessel is the stress-strain relationship. The nonlinear stress-strain relationship of arteries is best expressed as derivations of a strain-energy function. In this paper, the stress-strain relations are measured and the coefficients in the strain energy function of arteries are determined for diabetic and control rats. The meaning of these coefficients are explained. The influence of diabetes on the elastic property of the arteries is expressed by the changes of these coefficients. A point of departure of the present paper from all other blood vessel papers published so far is that all strains used here are referred to the zero-stress state of the arteries, whereas all other papers refer strains to the no-load state. The existence of a large difference between the zero-stress state and no-load state of arteries is one of our recent findings. We have explained that the use of zero-stress state as a basis of strain measurements reveals that the in vivo circumferential stress distribution is quite uniform in the vessel wall at the homeostatic condition. It also makes the strain energy function much more accurate than those in which the residual stress is ignored. Using these new results, the stress and strain distribution in normal and diabetic arteries are presented.     

Biaxial vasoactivity of porcine coronary artery

The passive mechanical properties of blood vessel mainly stem from the interaction of collagen and elastin fibers, but vessel constriction is attributed to smooth muscle cell (SMC) contraction. Although the passive properties of coronary arteries have been well characterized, the active biaxial stress-strain relationship is not known. Here, we carry out biaxial (inflation and axial extension) mechanical tests in right coronary arteries that provide the active coronary stress-strain relationship in circumferential and axial directions. Based on the measurements, a biaxial active strain energy function is proposed to quantify the constitutive stress-strain relationship in the physiological range of loading. The strain energy is expressed as a Gauss error function in the physiological pressure range. In K(+)-induced vasoconstriction, the mean ± SE values of outer diameters at transmural pressure of 80 mmHg were 3.41 ± 0.17 and 3.28 ± 0.24 mm at axial stretch ratios of 1.3 and 1.5, respectively, which were significantly smaller than those in Ca(2+)-free-induced vasodilated state (i.e., 4.01 ± 0.16 and 3.75 ± 0.20 mm, respectively). The mean ± SE values of the inner and outer diameters in no-load state and the opening angles in zero-stress state were 1.69 ± 0.04 mm and 2.25 ± 0.08 mm and 126 ± 22°, respectively. The active stresses have a maximal value at the passive pressure of 80-100 mmHg and at the active pressure of 140-160 mmHg. Moreover, a mechanical analysis shows a significant reduction of mean stress and strain (averaged through the vessel wall). These findings have important implications for understanding SMC mechanics.     

Regional distribution of axial strain and circumferential residual strain in the layered rabbit oesophagus

The oesophagus is subjected to large axial strains in vivo and the zero-stress state is not a closed cylinder but an open circular cylindrical sector. The closed cylinder with no external loads applied is called the no-load state and residual strain is the difference in strain between the no-load state and zero-stress state. To understand oesophageal physiology and pathophysiology, it is necessary to know the distribution of axial strain, the zero-stress state, the stress-strain relations of oesophageal tissue, and the changes of these states and relationships due to biological remodeling of the tissue under stress. This study is addressed to such biomechanical properties in normal rabbits. The oesophagi were marked on the surface in vivo, photographed, excised (in vitro state), photographed again, and sectioned into rings (no-load state) in an organ bath containing calcium-free Kreb's solution with dextran and EGTA added. The rings were cut radially to obtain the zero-stress state for the non-separated wall and further dissected to separate the muscle and submucosa layers. Equilibrium was awaited for 30min in each state and the specimens were photographed in no-load and the zero-stress states. The oesophageal length, circumferences, layer thicknesses and areas, and openings angle were measured from the digitised images. The oesophagus shortened axially by 35% after excision. The in vivo axial strain showed a significant variation with the highest values in the mid-oesophagus (p<0.001). Luminal area, circumferences, and wall and layer thicknesses and areas varied in axial direction (in all tests p<0.05). The residual strain was compressive at the mucosal surface and tensile at the serosal surface. The dissection studies demonstrated shear forces between the two layers in the non-separated wall in the no-load and zero-stress states. In conclusion, our data show significant axial variation in passive morphometric and biomechanical properties of the oesophagus. The oesophagus is a layered composite structure with nonlinear and anisotropic mechanical behaviour.     

Zero-stress states of arteries

The no-load configuration of a living organ is, in general, not the zero-stress state. The difference can be revealed by cutting up an unloaded organ to such an extent that the stress becomes zero in the tissue everywhere. For the aorta, it is shown that the configuration of the zero-stress state differs considerably from being a cylindrical tube. It is, in fact, an open sector with opening angles varying along the arterial tree. This article presents data on the zero-stress state in the arteries of the rat in normal condition.     

Some unusual considerations about vessel walls and wall stresses

The "zero-stress state" of blood vessels is usually defined with respect to the atmospheric pressure p(a) ( approximately 750 mmHg). As a consequence, circumferential and axial wall stresses due to a positive transmural pressure can only be positive and thus, by definition, only tensile. If the zero-stress state were defined with respect to vacuum pressure (0 mmHg), the compressive stress -p(a) generated by p(a) everywhere in the wall would, however, be included so that negative (=compressive) wall stresses would formally become possible. In order to examine the consequences this alternative definition would have for arteries, we have compared radial, circumferential, and axial stresses calculated "conventionally" to the values they take when the zero-stress state is defined "correctly" by reference to the vacuum pressure. It turns out that, under normal physiologic conditions, axial stress and perhaps also circumferential stress might well be compressive in many elastic and conductance arteries, contrary to the intuitive conviction of many people. Since the type of stresses a vessel wall is submitted to may be highly relevant for its structure and mechanical properties, this unconventional way of considering wall stresses may reveal unsuspected relationships between wall stresses on one side, and wall structure, vessel growth, adaptation and repair processes, atherosclerosis, angioplasty or stenting on the other side. Similar considerations might also prove useful with regard to cardiac hypertrophy.     

Transmural strain distribution in the blood vessel wall

The transmural distributions of stress and strain at the in vivo state have important implications for the physiology and pathology of the vessel wall. The uniform transmural strain hypothesis was proposed by Takamyzawa and Hayashi (Takamizawa K and Hayashi K. J Biomech 20: 7-17, 1987; Biorheology 25: 555-565, 1988) as describing the state of arteries in vivo. From this hypothesis, they derived the residual stress and strain at the no-load condition and the opening angle at the zero-stress state. However, the experimental evidence cited by Takamyzawa and Hayashi (J Biomech 20: 7-17, 1987; and Biorheology 25: 555-565, 1988) to support this hypothesis was limited to arteries whose opening angles (theta) are <180 degrees. It is well known, however, that theta > 180 degrees do exist in the cardiovascular system. Our hypothesis is that the transmural strain distribution cannot be uniform when theta; is >180 degrees. We present both theoretical and experimental evidence for this hypothesis. Theoretically, we show that the circumferential stretch ratio cannot physically be uniform across the vessel wall when theta; exceeds 180 degrees and the deviation from uniformity will increase with an increase in theta; beyond 180 degrees. Experimentally, we present data on the transmural strain distribution in segments of the porcine aorta and coronary arterial tree. Our data validate the theoretical prediction that the outer strain will exceed the inner strain when theta > 180 degrees. This is the converse of the gradient observed when the residual strain is not taken into account. Although the strain distribution may not be uniform when theta exceeds 180 degrees, the uniformity of stress distribution is still possible because of the composite nature of the blood vessel wall, i.e., the intima-medial layer is stiffer than the adventitial layer. Hence, the larger strain at the adventitia can result in a smaller stress because the adventitia is softer at physiological loading.     

Use of tensorial description in tissue remodeling: examples of F-actin distributions in pulmonary arteries in hypoxic hypertension

A molecular configuration tensor Pij was introduced to analyze the distribution of fibrous proteins in vascular cells for studying cells and tissues biomechanics. We have used this technique to study the biomechanics of vascular remodeling in response to the changes of blood pressure and flow. In this paper, the remodeling of the geometrical arrangement of F-actin fibers in the smooth muscle cells in rat's pulmonary arteries in hypoxic hypertension was studied. The rats were exposed to a hypoxia condition of 10% for 0, 2, 12, and 24 hr at sea level. Remodeling of blood vessels were studied at the in vivo state under normal perfusion, no-load state when small rings from blood vessels were excised, and zero-stress state after the rings were cut open radially to release the residual stress. Tissue remodeling in response to changes in blood pressure is reflected in the zero-stress state. The tensor components were determined by analyzing the configuration of phalloidin stained F-actin fibers in the media layer of pulmonary arteries. The values of P31, P32, P33 in the in-vivo state, the no-load state, and the zero-stress state are obtained. This study demonstrated the distributions of fibrous molecules in tissue remodeling can be described quantitatively using the molecular configuration tensor.     

Morphology and stress-strain properties along the small intestine in the rat

The stress-strain relationship is determined by the inherent mechanical properties of the intestinal wall, the geometric configurations, the loading conditions and the zero-stress state of the segment. The purpose of this project was to provide morphometric and biomechanical data for rat duodenum, jejunum and ileum. The circumferential strains were referenced to the zero-stress state. Large morphometric variations were found along the small intestine with an increase in the outer circumferential length and luminal area and a decrease in wall thickness in distal direction. The serosal residual strain was tensile and decreased in distal direction (P < 0.05). The mucosal residual strain was compressive and the absolute value decreased in distal direction (P < 0.001). The stress-strain experiments showed that the duodenum was stiffest. All segments were stiffest in longitudinal direction (P < 0.05). In conclusion, axial variation in morphometric and biomechanical properties was found in the small intestine. The zero-stress state must be considered in future biomechanical studies in the gastrointestinal tract.     

Biomechanical remodelling of obstructed guinea pig jejunum

Data on morphological and biomechanical remodelling are needed to understand the mechanisms behind intestinal obstruction. The effect of partial obstruction on mechanical properties with reference to the zero-stress state and on the histomorphological properties of the guinea pig small intestine was determined in this study. Partial obstruction and sham operation were surgically created in mid-jejunum of guinea pigs. The animals survived 2, 4, 7, and 14 days. The age-matched guinea pigs that were not operated served as normal controls. The segment proximal to the obstruction site was used for histological analysis, no-load state and zero-stress state data, and distension test. The segment for distension was immersed in an organ bath and inflated to 10 cm H₂O. The outer diameter change during the inflation was monitored using a microscope with CCD camera. Circumferential stresses and strains were computed from the diameter, pressure and the zero-stress state data. The opening angle and absolute value of residual strain decreased (P<0.01 and P<0.001) whereas the wall thickness, wall cross-sectional area, and the wall stiffness increased after 7 days obstruction (P<0.05, P<0.01). Histologically, the muscle and submucosa layers, especially the circumferential muscle layer increased in thickness after obstruction. The opening angle and residual strain mainly depended on the thickness of the muscle layer whereas the wall stiffness mainly depended on the thickness of the submucosa layer. In conclusion, the histomorphological and biomechanical properties of small intestine (referenced for the first time to the zero-stress state) remodel proximal to the obstruction site in a time-dependent manner.     

Regional distribution of layer-specific circumferential residual deformations and opening angles in the porcine aorta

Information on the layer-specific residual deformations of aortic tissue and how these vary throughout the vessel is important for understanding the regionally-varying aortic functions and pathophysiology, but not so much can be found in the literature. Toward this end, porcine aortas were sectioned into eighteen rings, with one ring from each anatomical position radially cut to obtain the zero-stress state for the intact wall and the other ring dissected into intimal-medial and adventitial layers; these rings were then radially cut to reach the zero-stress state for the intima-media and adventitia. Peripheral variations in internal/external circumferences, thickness, and opening angle of the intact wall and its layers were measured through image analysis at the no-load and zero-stress states. Intact wall and layer circumferences at both states significantly declined along the aorta, as did intact wall and intimal-medial but not adventitial thickness. Adventitia exhibited the greatest opening angles, approaching 180 deg all over the aorta. The opening angles of the intima-media and intact wall were quite similar, with the highest values in the ascending aorta, the lowest at the diaphragm, and increasing subsequently. Bending-related residual stretches were released by radial cutting that were compressive internally and tensile externally, displaying distinct axial variation for the intima-media and intact wall, and non-significant variation for the adventitia. Evidence is provided for the release upon layer separation of compressive stretches in the intima-media and of tensile stretches in the adventitia, whose values were smallest in the descending thoracic aorta and highest near the iliac artery bifurcation.     

The zero-stress state of rat veins and vena cava

The zero-stress state of a vein is, like that of an artery, not a closed cylindrical tube, but is a series of segments whose cross-sections are open sectors. An opening angle of each sector is defined as the angle subtended between two radii joining the midpoint of the inner wall to the tips of the inner wall. Data on the opening angles (mean +/- standard deviation) of the veins and vena cava of the rat are presented. For the superior vena cava and subclavian, jugular, facial, renal, common iliac, saphenous, and plantar veins, the opening angle varies in the range of 25 to 75 deg. The inferior vena cava (below the heart), however, has noncircular, nonaxisymmetric cross-sections, a curved axis, and a rapid longitudinal variation of its "diameter"; its zero-stress state is not circular sectors; but the opening angle is still a useful characterization. The mean opening angle of the interior vena cava varies in the range of 40 to 150 deg in the thoracic portion, and 75 to 130 deg in the abdominal portion, with the larger values occurring about the middle of each portion. There are considerable length, diameter reductions, and wall thickening of the vena cava from the homeostatic state to the no-load state in vitro. Physically, the zero-stress state is the basis of the stress analysis of blood vessels. The change of opening angle is a convenient parameter to characterize any nonuniform remodeling of the vessel wall due to changes in physical stress or chemical environment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Flow-induced shear strain in intima of porcine coronary arteries.

The in vivo circumferential strain has a small variation throughout the vascular system (aorta to arterioles). The axial strain has also been shown to be nearly the same as the circumferential strain under physiological loading. Since the endothelium is mechanically much softer than the media-adventitia in healthy arteries, the porcine intima was considered as a mechanically distinct layer from the media-adventitia in a two-layer computational model. Based on the simulation result, we hypothesize that the flow-induced shear strain in intima can be of similar value as the pressure-induced circumferential strain in healthy coronary arteries, even though the shear stress is orders of magnitude smaller than the circumferential stress. The nearly isotropic deformation (circumferential, axial, and shear strains) may have important implications for mechanical homeostasis of endothelial cells, mechanotransduction, growth, and remodeling of blood vessels.     

Diameter-dependent axial prestretch of porcine coronary arteries and veins

The pressure-diameter relation (PDR) and the wall strain of coronary blood vessels have important implications for coronary blood flow and arthrosclerosis, respectively. Previous studies have shown that these mechanical quantities are significantly affected by the axial stretch of the vessels. The objective of this study was to measure the physiological axial stretch in the coronary vasculature; i.e., from left anterior descending (LAD) artery tree to coronary sinus vein and to determine its effect on the PDR and hence wall stiffness. Silicone elastomer was perfused through the LAD artery and coronary sinus trees to cast the vessels at the physiologic pressure. The results show that the physiological axial stretch exists for orders 4 to 11 (> 24 μm in diameter) arteries and orders -4 to -12 (>38 μm in diameter) veins but vanishes for the smaller vessels. Statistically, the axial stretch is higher for larger vessels and is higher for arteries than veins. The axial stretch λ(z) shows a linear variation with the order number (n) as: λ(z) = 0.062n + 0.75 (R(2) = 0.99) for artery and λ(z) = -0.029n + 0.89 (R(2) = 0.99) for vein. The mechanical analysis shows that the axial stretch significantly affects the PDR of the larger vessels. The circumferential stretch/strain was found to be significantly higher for the epicardial arteries (orders 9-11), which are free of myocardium constraint, than the intramyocardial arteries (orders 4-8). These findings have fundamental implications for coronary blood vessel mechanics.     

Experimental investigation of collagen waviness and orientation in the arterial adventitia using confocal laser scanning microscopy

Mechanical properties of the adventitia are largely determined by the organization of collagen fibers. Measurements on the waviness and orientation of collagen, particularly at the zero-stress state, are necessary to relate the structural organization of collagen to the mechanical response of the adventitia. Using the fluorescence collagen marker CNA38-OG488 and confocal laser scanning microscopy, we imaged collagen fibers in the adventitia of rabbit common carotid arteries ex vivo. The arteries were cut open along their longitudinal axes to get the zero-stress state. We used semi-manual and automatic techniques to measure parameters related to the waviness and orientation of fibers. Our results showed that the straightness parameter (defined as the ratio between the distances of endpoints of a fiber to its length) was distributed with a beta distribution (mean value 0.72, variance 0.028) and did not depend on the mean angle orientation of fibers. Local angular density distributions revealed four axially symmetric families of fibers with mean directions of 0°, 90°, 43° and ?43°, with respect to the axial direction of the artery, and corresponding circular standard deviations of 40°, 47°, 37° and 37°. The distribution of local orientations was shifted to the circumferential direction when measured in arteries at the zero-load state (intact), as compared to arteries at the zero-stress state (cut-open). Information on collagen fiber waviness and orientation, such as obtained in this study, could be used to develop structural models of the adventitia, providing better means for analyzing and understanding the mechanical properties of vascular wall.     

Study on cartilaginous and muscular strains of rat trachea

Han and Fung (1991)[1] studied the zero-stressstates of porcine and canine tracheas by cutting themidpoints of cartilage and muscle respectively. Themethod of Fung, termed Once Cutting method in thispaper, was also used by Liu, Wang and Teng (2002)[2]in studying residual strain of rat tracheas. They all re-ported that the no-load state of trachea is not itszero-stress state, but the residual stress (strain) existsin no-load tracheal ring. The tracheal ring would openup into a figure of “C…     

Effects of biaxial stretch on arteriolar function in vitro

Mounting evidence suggests that the normal biomechanical state of arteries may include a nearly equibiaxial intramural stress and that arteries tend to undergo rapid and dramatic remodeling when perturbed from this normal state. Technical developments since the early 1980s have enabled in vitro (acute) and ex vivo (chronic culture) study of isolated, perfused microvessels, and it is clear that these vessels share many functional similarities with arteries. To date, however, there has been no systematic study of the effects of in-plane biaxial loading on the biomechanical behavior of arterioles. Here we describe a modification to a prior in vitro arterial test system that allowed us to investigate the role of altered axial stretch on the passive, myogenic, and norepinephrine-stimulated biaxial behavior of isolated rat cremaster arterioles. We show that axial stretches from 85% to 110% of values often used in the laboratory and consistent with those normally experienced in situ induce modest changes in the measured mean circumferential and axial stress-stretch behavior and in measures of distensibility and myogenic index. Nevertheless, altered axial stretch has a dramatic effect on the biaxial state of stress, and nearly equibiaxial stresses occur at axial stretches larger than those typically used in isolated arteriole studies. This finding is consistent with estimates of material and functional behavior in arterioles and suggests that long-term ex vivo studies, wherein vessel growth and remodeling are critical, should be performed at higher axial lengths than have been used during most prior in vitro tests.     

Distribution of stress and strain along the porcine aorta and coronary arterial tree

The existence of a homeostatic state of stresses and strains has been axiomatic in the cardiovascular system. The objective of this study was to determine the distribution of circumferential stress and strain along the aorta and throughout the coronary arterial tree to test this hypothesis. Silicone elastomer was perfused through the porcine aorta and coronary arterial tree to cast the arteries at physiological pressure. The loaded and zero-stress dimensions of the vessels were measured. The aorta (1.8 cm) and its secondary branches were considered down to 1.5 mm diameter. The left anterior descending artery (4.5 mm) and its branches down to 10 microm were also measured. The Cauchy mean circumferential stress and midwall stretch ratio were calculated. Our results show that the stretch ratio and Cauchy stress were lower in the thoracic than in the abdominal aorta and its secondary branches. The opening angle (theta) and midwall stretch ratio (lambda) showed a linear variation with order number (n) as follows: theta = 10.2n + 63.4 (R(2) = 0.989) and lambda = 4.47 x 10(-2)n + 1.1 (R(2) = 0.995). Finally, the stretch ratio and stress varied between 1.2 and 1.6 and between 10 and 150 kPa, respectively, along the aorta and left anterior descending arterial tree. The relative uniformity of strain (50% variation) from the proximal aorta to a 10-microm arteriole implies that the vascular system closely regulates the degree of deformation. This suggests a homeostasis of strain in the cardiovascular system, which has important implications for mechanotransduction and for vascular growth and remodeling.     

Postsurgical changes of the opening angle of canine autogenous vein graft.

The opening angles of 30 canine autogenous vein grafts were measured to determine the postsurgical change of residual strain in the vein graft. Canine femoral veins were grafted to femoral arteries in the end-to-end anastomosis fashion. When harvested, the vein grafts were cut into short segments and the segments were cut open radially. The opened-up configurations were taken as the zero-stress states of the vessels. Opening angle, defined as the angle between the two lines from the middle point to the tips of the inner wall, was used to describe the zero-stress states. Results show that the opening angles (mean +/- SD) are 63.0 +/- 30.6 deg for normal femoral veins, and -0.4 +/- 4.6, 6.1 +/- 19.4, 25.4 +/- 20.1, and 47.8 +/- 11.4 deg for vein grafts at 1 day, 1 week, 4 and 12 weeks postsurgery, respectively. The postsurgical changes in opening angle reveal nonuniform transmural tissue remodeling in the vascular wall. The relations between the changes in opening angle and the changes in the morphology of the vein grafts are discussed. Intimal hyperplasia is correlated to the opening angle and is suggested to be the main factor for the postsurgical increase in opening angle. The longitudinal strain in the vein graft is found to decrease postsurgically.