Computational analysis of type II endoleaks in a stented abdominal aortic aneurysm model

Insertion of a stent-graft into an aneurysm to form a new (synthetic) blood vessel and prevent the weakened artery wall from rupture is an attractive surgical intervention when compared to traditional open surgery. However, focusing on a stented abdominal aortic aneurysm (AAA), post-operative complications such as endoleaks may occur. An endoleak is the net influx of blood during the cardiac cycle into the cavity (or sac) formed by the stent-graft and the AAA wall. A natural endoleak source may stem from one or two secondary branches leading to and from the aneurysm, labeled types IIa and IIb endoleaks. Employing experimentally validated fluid-structure interaction solvers, the transient 3-D lumen and cavity blood flows, wall movements, pressure variations, maximum wall stresses and migration forces were computed for types IIa and IIb endoleaks. Simulation results indicate that the sac pressure caused by these endoleaks depends largely on the inlet branch pressure, where the branch inlet pressure increases, the sac pressure may reach the systemic level and AAA-rupture is possible. The maximum wall stress is typically located near the anterior-distal side in this model, while the maximum stent-graft stress occurs near the bifurcating point, in both cases, due to local stress concentrations. The time-varying leakage rate depends on the pressure difference between AAA sac and inlet branch. In contrast, the stent-graft migration force is reduced by type II endoleaks because it greatly depends on the pressure difference between the stent-graft and the aneurysm cavity.     

Biomechanics of abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is a condition whereby the terminal aorta permanently dilates to dangerous proportions, risking rupture. The biomechanics of AAA has been studied with great interest since aneurysm rupture is a mechanical failure of the degenerated aortic wall and is a significant cause of death in developed countries. In this review article, the importance of considering the biomechanics of AAA is discussed, and then the history and the state-of-the-art of this field is reviewed--including investigations into the biomechanical behavior of AAA tissues, modeling AAA wall stress and factors which influence it, and the potential clinical utility of these estimates in predicting AAA rupture.     

The ruptured abdominal aortic aneurysm—a diagnostic problem

The ruptured abdominal aortic aneurysm continues to be a diagnostic problem. Review of 187 cases admitted to the Vancouver General Hospital showed that 92 cases were operated on. Of this surgical group, the diagnosis was correct in 61 and missed in 31 (34%). In the group which did not come to operation the condition was diagnosed correctly in 38, while in 57 (60%) it was completely unsuspected. The effects of early and late diagnosis and misdiagnosis were reflected in the increasing mortality rate of 46, 55 and 100% respectively. Means of improving the accuracy of diagnosis in this condition are discussed.     

Hemodynamics of the mouse abdominal aortic aneurysm

The abdominal aortic aneurysm (AAA) is a significant cause of death and disability in the Western world and is the subject of many clinical and pathological studies. One of the most commonly used surrogates of the human AAA is the angiotensin II (Ang II) induced model used in mice. Despite the widespread use of this model, there is a lack of knowledge concerning its hemodynamics; this study was motivated by the desire to understand the fluid dynamic environment of the mouse AAA. Numerical simulations were performed using three subject-specific mouse models in flow conditions typical of the mouse. The numerical results from one model showed a shed vortex that correlated with measurements observed in vivo by Doppler ultrasound. The other models had smaller aneurysmal volumes and did not show vortex shedding, although a recirculation zone was formed in the aneurysm, in which a vortex could be observed, that elongated and remained attached to the wall throughout the systolic portion of the cardiac cycle. To link the hemodynamics with aneurysm progression, the remodeling that occurred between week one and week two of the Ang II infusion was quantified and compared with the hemodynamic wall parameters. The strongest correlation was found between the remodeled distance and the oscillatory shear index, which had a correlation coefficient greater than 0.7 for all three models. These results demonstrate that the hemodynamics of the mouse AAA are driven by a strong shear layer, which causes the formation of a recirculation zone in the aneurysm cavity during the systolic portion of the cardiac waveform. The recirculation zone results in areas of quiescent flow, which are correlated with the locations of the aneurysm remodeling.     

Evolving mechanical properties of a model of abdominal aortic aneurysm

The novel three-dimensional (3D) mathematical model for the development of abdominal aortic aneurysm (AAA) of Watton et al. Biomech Model Mechanobiol 3(2): 98–113, (2004) describes how changes in the micro-structure of the arterial wall lead to the development of AAA, during which collagen remodels to compensate for loss of elastin. In this paper, we examine the influence of several of the model’s material and remodelling parameters on growth rates of the AAA and compare with clinical data. Furthermore, we calculate the dynamic properties of the AAA at different stages in its development and examine the evolution of clinically measurable mechanical properties. The model predicts that the maximum diameter of the aneurysm increases exponentially and that the ratio of systolic to diastolic diameter decreases from 1.13 to 1.02 as the aneurysm develops; these predictions are consistent with physiological observations of Vardulaki et al. Br J Surg 85:1674–1680 (1998) and Lanne et al. Eur J Vasc Surg 6:178–184 (1992), respectively. We conclude that mathematical models of aneurysm growth have the potential to be useful, noninvasive diagnostic tools and thus merit further development.     

Preoperative evaluation of a patient for abdominal aortic aneurysm repair

Coexistent cardiovascular disease is common in patients presenting for repair of aortic aneurysms. However, preoperative cardiac evaluation prior to abdominal aortic aneurysm (AAA) surgery remains contentious with significant variations in practice between countries, institutions and individual anesthetists. The following case report raises some everyday issues confronting clinical anesthetists.     

Urinoma: a rare complication of abdominal aortic aneurysm surgery

Urinoma or para-renal pseudocyst generally occurs as a result of trauma to the pelvi-ureteric system. It consists of an encapsulated collection of extravasated urine and is usually located in the peri-renal space or more uncommonly in the peritoneal, pleural or mediastinal cavities. There is only one previously reported case of urinoma secondary to abdominal aortic aneurysm (AAA) surgery. We report a case of symptomatic urinoma after infra-renal AAA repair and discuss the etiology, diagnosis and treatment of this unusual condition.     

Stereoscopically observed deformations of a compliant abdominal aortic aneurysm model

A new experimental setup has been implemented to precisely measure the deformations of an entire model abdominal aortic aneurysm (AAA). This setup addresses a gap between the computational and experimental models of AAA that have aimed at improving the limited understanding of aneurysm development and rupture. The experimental validation of the deformations from computational approaches has been limited by a lack of consideration of the large and varied deformations that AAAs undergo in response to physiologic flow and pressure. To address the issue of experimentally validating these calculated deformations, a stereoscopic imaging system utilizing two cameras was constructed to measure model aneurysm displacement in response to pressurization. The three model shapes, consisting of a healthy aorta, an AAA with bifurcation, and an AAA without bifurcation, were also evaluated with computational solid mechanical modeling using finite elements to assess the impact of differences between material properties and for comparison against the experimental inflations. The device demonstrated adequate accuracy (surface points were located to within 0.07?mm) for capturing local variation while allowing the full length of the aneurysm sac to be observed at once. The experimental model AAA demonstrated realistic aneurysm behavior by having cyclic strains consistent with reported clinical observations between pressures 80 and 120?mm Hg. These strains are 1-2%, and the local spatial variations in experimental strain were less than predicted by the computational models. The three different models demonstrated that the asymmetric bifurcation creates displacement differences but not cyclic strain differences within the aneurysm sac. The technique and device captured regional variations of strain that are unobservable with diameter measures alone. It also allowed the calculation of local strain and removed rigid body motion effects on the strain calculation. The results of the computations show that an asymmetric aortic bifurcation created displacement differences but not cyclic strain differences within the aneurysm sac.     

Inflammatory markers associated with abdominal aortic aneurysm

Purpose

Inflammation with leukocytic infiltration, degradation of extracellular matrix (ECM), and depletion of vascular smooth muscle cells (VSMC) are pathological hallmarks of abdominal aortic aneurysm (AAA). The aim of this study was to further evaluate relationships betweenAAAand inflammatory biomarkers, interleukin- 6 (IL-6), tumour necrosis factor-α (TNF-α), endothelin-1 (ET-1) and soluble urokinase-type plasminogen activator receptor (suPAR), by comparing levels in 65-year-old men with and without AAA at ultrasound screening.We also evaluated whether any biomarker can independently predict AAA at screening, and clarified potential correlations between aortic diameter and blood levels of these biomarkers.

Results

There were significant (p ? 0.05) differences between subjects with and without AAA for the following variables: p-leukocyte count (TLC) (p<0.001), p-homocysteine (p<0.001), p-TNF-α (p = 0.023), p-IL-6 (p<0.001), p-ET-1 (p = 0.002), p-suPAR (p<0.001), ankle brachial index (ABI) (p<0.001), plasma (p)-creatinine (p = 0.049), p-total cholesterol (p<0.001), p-high density lipoprotein (HDL) (p<0.001) and low density lipoprotein (LDL) cholesterol (p = 0.001), smoking habits (p<0.001), and use of antihypertensive (p<0.001) and lipid-lowering (p = 0.001) drugs. When the above variables were stepwise excluded in a logistic regression model, only p-IL-6 (p = 0.002), p-homocysteine (p = 0.015), p-HDL (p = 0.004), ABI in the right (p = 0.005) and left (p = 0.094) leg, smoking habits (p = 0.003), and antihypertensive drug use (p = 0.045), differed between groups. Significant correlations with aortic diameter existed for p-TNF-α (p = 0.028), p-IL-6 (p<0.001), p-ET-1 (p = 0.002) and p-suPAR (p<0.001) in the entire study population, and for p-TNF-α (p = 0.023), p-ET-1 (p = 0.009) and p-suPAR (p = 0.001) among men with AAA.

Conclusions

Several inflammatory biomarkers were significantly elevated and correlated with aortic diameter among 65-year old men with AAA at ultrasound screening. IL-6, homocysteine and use of antihypertensive medication remained elevated in the logistic regression model, together with known risk markers for AAA such as smoking and signs of atherosclerosis.

     

Non-linear viscoelastic behavior of abdominal aortic aneurysm thrombus

The objective of this work was to determine the linear and non-linear viscoelastic behavior of abdominal aortic aneurysm thrombus and to study the changes in mechanical properties throughout the thickness of the thrombus. Samples are gathered from thrombi of seven patients. Linear viscoelastic data from oscillatory shear experiments show that the change of properties throughout the thrombus is different for each thrombus. Furthermore the variations found within one thrombus are of the same order of magnitude as the variation between patients. To study the non-linear regime, stress relaxation experiments are performed. To describe the phenomena observed experimentally, a non-linear multimode model is presented. The parameters for this model are obtained by fitting this model successfully to the experiments. The model cannot only describe the average stress response for all thrombus samples but also the highest and lowest stress responses. To determine the influence on the wall stress of the behavior observed the model proposed needs to implemented in the finite element wall stress analysis.     

On the inheritance of abdominal aortic aneurysm.

To determine the mode of inheritance of abdominal aortic aneurysm, data on first-degree relatives of 91 probands were collected. Results of segregation analysis performed on these data are reported. Many models, including nongenetic and genetic models, were compared using likelihood methods. The nongenetic model was rejected; statistically significant evidence in favor of a genetic model was found. Among the many genetic models compared, the most parsimonious genetic model was that susceptibility to abdominal aortic aneurysm is determined by a recessive gene at an autosomal diallelic major locus. A multifactorial component in addition to the major locus does not increase the likelihood of the data significantly.     

Prestressing in finite deformation abdominal aortic aneurysm simulation

In abdominal aortic aneurysm (AAA) simulation the patient-specific geometry of the object of interest is very often reconstructed from in vivo medical imaging such as CT scans. Such geometries represent a deformed configuration stressed by typical in vivo conditions. However, commonly, such structures are considered stress-free in simulation. In this contribution we sketch and compare two methods to introduce a physically meaningful stress/strain state to the obtained geometry for simulations in the finite strain regime and demonstrate the necessity of such prestressing techniques. One method is based on an inverse design analysis to calculate a stress-free reference configuration. The other method developed here is based on a modified updated Lagrangian formulation. Formulation of both methods is provided. Applicability and accurateness of both approaches are compared and evaluated utilizing fully three-dimensional patient-specific AAA structures in the finite strain regime.     

Cathepsin A activity of a parietal thrombus of an abdominal aortic aneurysm

We evaluated the cathepsin A activity of a parietal thrombus of an abdominal aortic aneurysm. We compared this activity to that of a retracted blood clot homogenate. Cathepsin A of aneurysm parietal thrombus homogenate and blood clot homogenate showed the highest activity on Z-Phe-Ala. It was lower on Z-Phe-Phe, Z-Glu-Tyr, Z-Glu-Phe, Z-Gly-Phe, and the lowest activity was on Z-Gly-Ala. We conclude that cathepsin A's activity on a parietal thrombus of an aneurysm is much higher than blood clot cathepsin A activity.