Hydrodynamic effects of compliance mismatch in stented arteries

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

Effects of stent porosity on hemodynamics in a sidewall aneurysm model

Computation and experiment have been complementarily performed to study the fluid flow inside a stented lateral aneurysm anchored on the straight parent vessel. The implicit solver was based on the time-dependent incompressible Navier-Stokes equations of laminar flow. Solutions were generated by a cell-center finite-volume method that used second-order upwind and second-order center flux difference splitting for the convection and diffusion term, respectively. The second-order Crank-Nicolson method was used in the time integration term. Experimental techniques used were flow visualization (FV) and particle tracking velocimetry (PTV). Experimentally, the straight afferent vessel had an inner diameter 10mm. The diameters of the aneurysmal orifice, neck, and fundus were 14, 10, and 15 mm, respectively, and the distance between the orifice and dome measured 20mm. A 30 mm long helix-shaped stent was tested. Four stent porosities of 100%, 70%, 50%, and 25% were examined. Volume-flow rate waveform of a cerebral artery was considered with a maximum Reynolds number of 250 and Womersley number of 3.9. Results are presented in terms of the pulsatile main and secondary flow velocity vector fields, the volume inflow rates into the aneurysm, and the wall shear stress (WSS) and wall pressure at the aneurysm dome. Some comparisons of computed results with the present FV and PTV results and with the data available from the literature are also made. The maximum flow velocity inside the aneurysm ostium and the WSS in the dome region at the peak flow can, respectively, be suppressed to less than 5% of the parent vessel bulk velocity (or 20% of the unstented case) and 8% of the unstented case if the stent porosity is smaller than 40% (about the porosity of the two-layer stents). In general, the three-layer stents seem not as effective as the two-layer stents in reducing the magnitude of aneurysm inflow rate and WSS.     

Finite-element modeling of the hemodynamics of stented aneurysms

BACKGROUND: Computational fluid dynamics (CFD) simulations are used to analyze the wall shear stress distribution and flow streamlines near the throat of a stented basilar side-wall aneurysm. Previous studies of stented aneurysm flows used low mesh resolution, did not include mesh convergence analyses, and depended upon conformal meshing techniques that apply only to very artificial stent geometries. METHOD OF APPROACH: We utilize general-purpose computer assisted design and unstructured mesh generation tools that apply in principle to stents and vasculature of arbitrary complexity. A mesh convergence analysis for stented steady flow is performed, varying node spacing near the stent. Physiologically realistic pulsatile simulations are then performed using the converged mesh. RESULTS: Artifact-free resolution of the wall shear stress field on stent wires requires a node spacing of approximately 1/3 wire radius. Large-scale flow features tied to the velocity field are, however, captured at coarser resolution (nodes spaced by about one wire radius or more). CONCLUSIONS: Results are consistent with previous work, but our methods yield more detailed insights into the complex flow dynamics. However, routine applications of CFD to anatomically realistic cases still depend upon further development of dedicated algorithms, most crucially to handle geometry definition and mesh generation for complicated stent deployments.     

Numerical simulation of hemodynamics in stented internal carotid aneurysm based on patient-specific model

There is still a considerable lack of quantitative information concerning the effects of stent structures on blood flow in an aneurismal cavity. In this paper, five virtual stents with different structures and wire cross-sections were designed for incorporation into the same patient-specific aneurysm model. Computational fluid dynamics simulations were performed so as to study how these five types of stents modified hemodynamic parameters. Numerical results demonstrated that the mean flow rate in the aneurismal cavity decreased the most in the model that used a stent with a rectangular wire cross-section, and that the wall shear stresses at the dome and neck of the aneurysm decreased more in models that used a stent with a circular wire cross-section or a spiral stent with a rectangular wire cross-section compared to other models. In addition, the wall pressure on the aneurysm increased slightly after implantation of the stent in all five models. This result differs from that previously published, and may help guide the design and assist clinicians in selecting an appropriate stent for treating cerebral aneurysms.     

Changes in the mechanical environment of stenotic arteries during interaction with stents: computational assessment of parametric stent designs

Clinical studies have identified factors such as the stent design and the deployment technique that are one cause for the success or failure of angioplasty treatments. In addition, the success rate may also depend on the stenosis type. Hence, for a particular stenotic artery, the optimal intervention can only be identified by studying the influence of factors such as stent type, strut thickness, geometry of the stent cell, and stent-artery radial mismatch with the wall. We propose a methodology that allows a set of stent parameters to be varied, with the aim of evaluating the difference in the mechanical environment within the wall before and after angioplasty with stenting. Novel scalar quantities attempt to characterize the wall changes inform of the contact pressure caused by the stent struts, and the stresses within the individual components of the wall caused by the stent. These quantities are derived numerically and serve as indicators, which allow the determination of the correct size and type of the stent for each individual stenosis. In addition, the luminal change due to angioplasty may be computed as well. The methodology is demonstrated by using a full three-dimensional geometrical model of a postmortem specimen of a human iliac artery with a stenosis using imaging data. To describe the material behavior of the artery, we considered mechanical data of eight different vascular tissues, which formed the stenosis. The constitutive models for the tissue components capture the typical anisotropic, nonlinear and dissipative characteristics under supra-physiological loading conditions. Three-dimensional stent models were parametrized in such a way as to enable new designs to be generated simply with regard to variations in their geometric structure. For the three-dimensional stent-artery interaction we use a contact algorithm based on smooth contact surfaces of at least C-continuity, which prevents numerical problems known from standard facet-based contact algorithm. The proposed methodology has the potential to provide a scientific basis for optimizing treatment procedures and stent geometries and materials, to help stent designers examine new stent designs "virtually," and to assist clinicians in choosing the most suitable stent for a particular stenosis.     

Effects of stent stiffness on local haemodynamics with particular reference to wave reflections

The placement of a rigid stent within an elastic vessel produces wave reflection sites at the entrance to and exit from the stent. The net haemodynamic effects of these reflections depend critically on the degree of stiffness of the stent and on its length and position within the diseased vessel, variables that have been found to affect the clinical performance of a stent. Here these effects are examined analytically, using a segmented tube model. The results indicate that the presence of the stent within the larger diseased vessel has the effect of producing higher pressure at the vessel entrance than that at exit. This pressure difference, when superimposed on the underlying pressure distribution within the vessel, has the net effect of actually aiding rather than impeding the flow, but the extent of this depends on the length and position of the stent. A short stent placed near the entrance of the diseased vessel may be favoured clinically for producing the least perturbation in the underlying haemodynamics and thus reducing the chance of restenosis, while a long stent placed near the exit may be favoured for producing a positive pressure difference and thus aiding the flow.     

Effects of major endoleaks on a stented abdominal aortic aneurysm

Insertion of a stent-graft into an aneurysm, especially abdominal aortic aneurysms (AAAs), is a very attractive surgical intervention; however, it is not without major postoperative complications, such as endoleaks. An endoleak is the transient accumulation of blood in the AAA cavity, which is formed by the stent-graft and AAA walls. Of the four blood pathways, a type I endoleak constitutes the major one. Thus, focusing on both proximal and distal type I endoleaks, i.e., the minute net influx of blood past the attachment points of a stent-graft into the AAA cavity, the transient three-dimensional interactions between luminal blood flow stent-graft wall, leakage flow, and AAA wall are computationally simulated. For different type I endoleak scenarios and inlet pressure wave forms, the impact of type I endoleaks on cavity pressure, wall stress, and stent-graft migration force is analyzed. The results indicate that both proximal type I-a and distal type I-b endoleaks may cause cavity pressures close to a patient's systemic pressure; however, with reduced pulsatility. As a result, the AAA-wall stress is elevated up to the level of a nonstented AAA and, hence, such endoleaks render the implant useless in protecting the AAA from possible rupture. Interestingly enough, the net downward force acting on the implant is significantly reduced; thus, in the presence of endoleaks, the risk of stent-graft migration may be mitigated.     

Numerical analysis of hemodynamics in spastic middle cerebral arteries

Cerebral vasospasm (CVS) is the most common serious complication of subarachnoid hemorrhage. Among the many factors that are associated with the pathogenesis of CVS, hemodynamics plays an important role in the initiation and development of CVS. Numerical simulation was carried out to obtain the flow patterns and wall shear stress (WSS) distribution in spastic middle cerebral arteries. The blood was assumed to be incompressible, laminar, homogenous, Newtonian, and steady. Our simulations reveal that flow velocity and WSS level increase at the stenosis segment of the spastic vessels, but further downstream of stenosis, the WSS significantly decreases along the inner wall, and flow circulation and stagnation are observed. The hydrodynamic resistance increases with the increase of vessel spasm. Moreover, the change of flow field and hydrodynamic forces are not linearly proportional to the spasm level, and the rapid change of hemodynamic parameters is observed as the spasm is more than 50%. Accordingly, in the view of hemodynamic physiology, vessels with less than 30% stenosis are capable of self-restoration towards normal conditions. However, vessels with more than 50% stenosis may eventually lose their capacity to adapt to differing physiologic conditions due to the extreme non-physilogic hemodynamic environment, and the immediate expansion of the vessel lumen might be needed to minimize serious and non-reversible effects.     

不同麻醉方式对老年冠心病患者围术期血流动力学及ECG的影响

目的：探讨对择期腹部手术的老年冠心病患者心脏血流动力学及心脏电活动影响较小的麻醉方式。方法：133例择期腹腔手术的老年冠心病患者随机分为硬膜外麻醉组（EA）,全麻组（GA）和腰-硬联合麻醉组（CSEA）。术中连续监测,分时段记录平均动脉压（MAP）、心率（HR）、血氧饱和度（SaO2）及异常心电图,比较3组组间及组内差异。结果：麻醉后15 min和麻醉后30 min,GA组的SaO2明显高于EA组（P〈0.05）。麻醉后15min、30 min和60 min CSEA组MAP值比EA组明显升高（P〈0.05）;麻醉后30 min,CSEA组的HR比EA组明显升高（P〈0.05）;麻醉后15 min和30 min,CSEA组的SaO2比EA组明显升高（P〈0.05）。组内比较,EA组麻醉后15min、30 min、60 min,MAP、HR、SaO2三个指标均比麻醉前明显降低（P〈0.05）,GA组和CSEA组前后比较差异不明显（P〉0.05）。异常ECG,组间比较,GA组和CSEA组ST-T改变发生率在麻醉后15 min、30 min、60 min、术毕时均明显低于EA组（P〈0.05,P〈0.01）,GA组和CSEA组心律失常发生率在麻醉后15 min、30 min、60 min均明显低于EA组（P〈0.05,P〈0.01）;组内比较,GA组和CSEA组的ST-T改变和心律失常发生率在麻醉后15 min、30min、60 min、术毕时均明显低于麻醉前（P〈0.05,P〈0.01）。结论：老年冠心病患者腹腔手术时全麻和腰-硬联合麻醉术中血流动力学较稳定,心电异常发生率较小。     

不同海拔高度对健康成年男性心脏血流动力学和心电图的影响

目的:监测中国南极冰盖考察预选队员心血管系统随海拔增高的变化,探讨筛查低氧易感队员和急性高原病的防治。方法:用无创血流动力学监护仪和十二导联心电图机,在北京(40 m)、拉萨(3 650 m)、羊八井(4 300 m)对第25次和26次南极冰盖考察预选队员心血管功能进行连续动态性监测。结果:随着海拔的增高,心率、收缩压、舒张压、平均动脉压、外周血管阻力、外周血管阻力指数显著升高(P0.05),心输出量、心指数、搏出量、搏出指数、加速度指数、速度指数、左心射血时间显著降低(P0.05),预射血期呈降低趋势(P0.05)。结论:随着海拔的增高,预选队员的外周血管阻力显著升高,左心泵血和收缩功能减弱且与Q-TC间期呈负相关。     

Plaque-prone hemodynamics impair endothelial function in pig carotid arteries

Hemodynamic forces play an active role in vascular pathologies, particularly in relation to the localization of atherosclerotic lesions. It has been established that low shear stress combined with cyclic reversal of flow direction (oscillatory shear stress) affects the endothelial cells and may lead to an initiation of plaque development. The aim of the study was to analyze the effect of hemodynamic conditions in arterial segments perfused in vitro in the absence of other stimuli. Left common porcine carotid segments were mounted into an ex vivo arterial support system and perfused for 3 days under unidirectional high and low shear stress (6 +/- 3 and 0.3 +/- 0.1 dyn/cm(2)) and oscillatory shear stress (0.3 +/- 3 dyn/cm(2)). Bradykinin-induced vasorelaxation was drastically decreased in arteries exposed to oscillatory shear stress compared with unidirectional shear stress. Impaired nitric oxide-mediated vasodilation was correlated to changes in both endothelial nitric oxide synthase (eNOS) gene expression and activation in response to bradykinin treatment. This study determined the flow-mediated effects on native tissue perfused with physiologically relevant flows and supports the hypothesis that oscillatory shear stress is a determinant factor in early stages of atherosclerosis. Indeed, oscillatory shear stress induces an endothelial dysfunction, whereas unidirectional shear stress preserves the function of endothelial cells. Endothelial dysfunction is directly mediated by a downregulation of eNOS gene expression and activation; consequently, a decrease of nitric oxide production and/or bioavailability occurs.     

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

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

Long-term clinical outcome after stent implantation in coronary arteries

The long-term clinical outcome after planned and unplanned stent implantation was assessed in a single-center, observational study in 178 patients who underwent coronary stent implantation between November 1986 and July 1994. Main outcome measures were survival and event-free survival at 5 years (Kaplan-Meier method). Independent predictors for event-free survival were determined by using multivariate logistic regression analysis. Patients underwent planned (group 1, n 3 101) or unplanned (group 2, n 3 77) stent implantation. During the in-hospital period, there were no deaths. The incidence of Q-wave and non-Q-wave acute myocardial infarction (AMI), coronary artery bypass graft (CABG) and repeat percutaneous transluminal coronary angioplasty (PTCA) was 5.0%, 2.0% and 4.0%, respectively, in group 1, versus 32.5%, 23.4% and 10.4%, respectively, in group 2. During the follow-up period (median 4.0 years, range 0.29-9.8 years), the incidence of death, AMI, and repeat revascularization (CABG and PTCA) was 5.9%, 8.9% and 40.6%, respectively, in group 1, versus 1.3%, 5.2% and 36.4%, respectively, in group 2. Survival and event-free survival at 5 years was 73 (7%) and 47 (7%), respectively, for patients who underwent planned stent implantation. It was 98 (0.1%) and 34 (6%), respectively, for patients who underwent unplanned stent implantation. At the end of follow-up, 31.9% of patients had angina pectoris class III or IV (Canadian Cardiovascular Society). The long-term clinical outcome after both planned and unplanned stent implantation was characterized by a high incidence of repeat revascularization. It is conceivable that changes in stent design and implantation techniques, in addition to novel therapeutic approaches addressing neointima formation and progression of atherosclerosis, may improve the long-term clinical outcome.     

Influence of shape-memory stent grafts on local aortic compliance

The effect of repair techniques on the biomechanics of the aorta is poorly understood, resulting in significant levels of postoperative complications for patients worldwide. This study presents a computational analysis of the influence of Nitinol-based devices on the biomechanical performance of a healthy patient-specific human aorta. Simulations reveal that Nitinol stent-grafts stretch the artery wall so that collagen is stretched to a straightened high-stiffness configuration. The high-compliance regime (HCR) associated with low diastolic lumen pressure is eliminated, and the artery operates in a low-compliance regime (LCR) throughout the entire cardiac cycle. The slope of the lumen pressure–area curve for the LCR post-implantation is almost identical to that of the native vessel during systole. This negligible change from the native LCR slope occurs because the stent-graft increases its diameter from the crimped configuration during deployment so that it reaches a low-stiffness unloading plateau. The effective radial stiffness of the implant along this unloading plateau is negligible compared to the stiffness of the artery wall. Provided the Nitinol device unloads sufficiently during deployment to the unloading plateau, the degree of oversizing has a negligible effect on the pressure–area response of the vessel, as each device exerts approximately the same radial force, the slope of which is negligible compared to the LCR slope of the native artery. We show that 10% oversizing based on the observed diastolic diameter in the mid descending thoracic aorta results in a complete loss of contact between the device and the wall during systole, which could lead to an endoleak and stent migration. 20% oversizing reaches the Dacron enforced area limit (DEAL) during the pulse pressure and results in an effective zero-compliance in the later portion of systole.

     

Effects of different doses of perfluorocarbon emulsion on hemodynamics and contractility of ischemic heart]

The effect of different doses of perfluorocarbon emulsion (5, 10, and 15 ml/kg) on the hemodynamics and contractility of heart was studied on anesthetized dogs. The emulsion was introduced intravenously by the 60th minute of acute myocardium ischemia caused by partial coronary occlusion. When pO2 = 120 mm Hg, the emulsion was efficient only at doses of 10 and 15 ml/kg (an increase in cardiac ejection, in the rate of contraction and relaxation of the myocardium, reduction of vascular resistance). However, the efficiency of the emulsion at a dose of 15 ml/kg was lower, possibly, due to hypervolemia and cardiodepressive effect of introduction of excess quantity of the surface-active substance proxanol, a component of the emulsion.     

Effects of anesthetics on systemic hemodynamics in mice

The aim of this study was to compare the systemic hemodynamic effects of four commonly used anesthetic regimens in mice that were chronically instrumented for direct and continuous measurements of cardiac output (CO). Mice (CD-1, Swiss, and C57BL6 strains) were instrumented with a transit-time flow probe placed around the ascending aorta for CO measurement. An arterial catheter was inserted into the aorta 4 or 5 days later for blood pressure measurements. After full recovery, hemodynamic parameters including stroke volume, heart rate, CO, mean arterial pressure (MAP), and total peripheral resistance were measured with animals in the conscious state. General anesthesia was then induced in these mice using isoflurane (Iso), urethane, pentobarbital sodium, or ketamine-xylazine (K-X). The doses and routes of administration of these agents were given as required for general surgical procedures in these animals. Compared with the values obtained for animals in the conscious resting state, MAP and CO decreased during all anesthetic interventions, and hemodynamic effects were smallest for Iso (MAP, -24 +/- 3%; CO, -5 +/- 7%; n = 15 mice) and greatest for K-X (MAP, -51 +/- 6%; CO, -37 +/- 9%; n = 8 mice), respectively. The hemodynamic effects of K-X were fully antagonized by administration of the alpha(2)-receptor antagonist atipamezole (n = 8 mice). These results indicate that the anesthetic Iso has fewer systemic hemodynamic effects in mice than the nonvolatile anesthetics.