A Comparison of Diameter,Wall Stress,and Rupture Potential Index for Abdominal Aortic Aneurysm Rupture Risk Prediction

An abdominal aortic aneurysm (AAA) is a balloon-like dilation of the aorta, which is potentially fatal in case of rupture. Computational finite element (FE) analysis is a promising approach to a more accurate and patient-specific rupture risk prediction. AAA wall strength and rupture potential index (RPI) calculation are implemented in our FE software. Static structural FE simulations are performed on n = 30 non-ruptured asymptomatic, n = 9 non-ruptured symptomatic, and n = 14 ruptured AAAs. We calculate maximum values for diameter, wall displacement, strain, stress, and RPI as well as minimum wall strength for every AAA. All investigated quantities, except minimum strength, show statistically significant differences between non-ruptured asymptomatic and symptomatic/ruptured AAAs. Maximum wall stress and especially the RPI are notably increased for symptomatic and ruptured AAAs. The biggest difference is found to be the RPI (Δ = 44.9%, p = 8.0e−5). Lowest RPI obtained for symptomatic or ruptured AAAs is 0.3. The RPI of more than 55% of the investigated asymptomatic AAAs falls below this value. Maximum wall stress and maximum RPI criteria enable a reliable rupture risk evaluation for AAAs. Especially in the diameter range where surgical indication is not obvious, the RPI holds great potential for improvement of clinical decisions.     

Quantification of particle residence time in abdominal aortic aneurysms using magnetic resonance imaging and computational fluid dynamics

Hemodynamic conditions are hypothesized to affect the initiation, growth, and rupture of abdominal aortic aneurysms (AAAs), a vascular disease characterized by progressive wall degradation and enlargement of the abdominal aorta. This study aims to use magnetic resonance imaging (MRI) and computational fluid dynamics (CFD) to quantify flow stagnation and recirculation in eight AAAs by computing particle residence time (PRT). Specifically, we used gadolinium-enhanced MR angiography to obtain images of the vessel lumens, which were used to generate subject-specific models. We also used phase-contrast MRI to measure blood flow at supraceliac and infrarenal locations to prescribe physiologic boundary conditions. CFD was used to simulate pulsatile flow, and PRT, particle residence index, and particle half-life of PRT in the aneurysms were computed. We observed significant regional differences of PRT in the aneurysms with localized patterns that differed depending on aneurysm geometry and infrarenal flow. A bulbous aneurysm with the lowest mean infrarenal flow demonstrated the slowest particle clearance. In addition, improvements in particle clearance were observed with increase of mean infrarenal flow. We postulate that augmentation of mean infrarenal flow during exercise may reduce chronic flow stasis that may influence mural thrombus burden, degradation of the vessel wall, and aneurysm growth.     

Effects of blood flow and vessel geometry on wall stress and rupture risk of abdominal aortic aneurysms

Sudden rupture of abdominal aortic aneurysm (AAA), often without prior medical warning, is the 13th leading cause of mortality in the US. The local rupture is triggered when the elusive maximum local wall stress exceeds the patient's yield stress. Employing a validated fluid – structure interaction code, the coupled blood flow and AAA wall dynamics were simulated and analysed for two representative asymmetric AAAs with different neck angles and iliac bifurcations. It turned out that the AAA morphology plays an important role in wall deformation and stress distribution, and hence possible rupture. The neck angle substantially impacts flow fields. A large neck angle may cause strong irregular vortices in the AAA cavity and may influence the wall stress distribution remarkably. The rupture risk of lateral asymmetric AAAs is higher than for the anterior – posterior asymmetric types. The most likely rupture site is located near the anterior distal side for the anterior – posterior asymmetric AAA and the left distal side in the lateral asymmetric AAA.     

Quantitative assessment of abdominal aortic aneurysm geometry

Recent studies have shown that the maximum transverse diameter of an abdominal aortic aneurysm (AAA) and expansion rate are not entirely reliable indicators of rupture potential. We hypothesize that aneurysm morphology and wall thickness are more predictive of rupture risk and can be the deciding factors in the clinical management of the disease. A non-invasive, image-based evaluation of AAA shape was implemented on a retrospective study of 10 ruptured and 66 unruptured aneurysms. Three-dimensional models were generated from segmented, contrast-enhanced computed tomography images. Geometric indices and regional variations in wall thickness were estimated based on novel segmentation algorithms. A model was created using a J48 decision tree algorithm and its performance was assessed using ten-fold cross validation. Feature selection was performed using the χ²-test. The model correctly classified 65 datasets and had an average prediction accuracy of 86.6% (κ = 0.37). The highest ranked features were sac length, sac height, volume, surface area, maximum diameter, bulge height, and intra-luminal thrombus volume. Given that individual AAAs have complex shapes with local changes in surface curvature and wall thickness, the assessment of AAA rupture risk should be based on the accurate quantification of aneurysmal sac shape and size.     

The Effects of Anisotropy on the Stress Analyses of Patient-Specific Abdominal Aortic Aneurysms

The local dilation of the infrarenal abdominal aorta, termed an abdominal aortic aneurysm (AAA), is often times asymptomatic and may eventually result in rupture—an event associated with a significant mortality rate. The estimation of in-vivo stresses within AAAs has been proposed as a useful tool to predict the likelihood of rupture. For the current work, a previously-derived anisotropic relation for the AAA wall was implemented into patient-specific finite element simulations of AAA. There were 35 AAAs simulated in the current work which were broken up into three groups: elective repairs (n = 21), non-ruptured repairs (n = 5), and ruptured repairs (n = 9). Peak stresses and strains were compared using the anisotropic and isotropic constitutive relations. There were significant increases in peak stress when using the anisotropic relationship (p < 0.001), even in the absence of the ILT (p = 0.014). Rutpured AAAs resulted in elevated peak stresses as compared to non-ruptured AAAs when using both the isotropic and anisotropic simulations, however these comparisons did not reach significance (p _ani = 0.55, p _iso = 0.73). While neither the isotropic or anisotropic simulations were able to significantly discriminate ruptured vs. non-ruptured AAAs, the lower p-value when using the anisotropic model suggests including it into patient-specific AAAs may help better identify AAAs at high risk.     

Hemodynamic Changes Quantified in Abdominal Aortic Aneurysms with Increasing Exercise Intensity Using MR Exercise Imaging and Image-Based Computational Fluid Dynamics

Abdominal aortic aneurysm (AAA) is a vascular disease resulting in a permanent, localized enlargement of the abdominal aorta. We previously hypothesized that the progression of AAA may be slowed by altering the hemodynamics in the abdominal aorta through exercise [Dalman, R. L., M. M. Tedesco, J. Myers, and C. A. Taylor. Ann. N.Y. Acad. Sci. 1085:92–109, 2006]. To quantify the effect of exercise intensity on hemodynamic conditions in 10 AAA subjects at rest and during mild and moderate intensities of lower-limb exercise (defined as 33 ± 10% and 63 ± 18% increase above resting heart rate, respectively), we used magnetic resonance imaging and computational fluid dynamics techniques. Subject-specific models were constructed from magnetic resonance angiography data and physiologic boundary conditions were derived from measurements made during dynamic exercise. We measured the abdominal aortic blood flow at rest and during exercise, and quantified mean wall shear stress (MWSS), oscillatory shear index (OSI), and particle residence time (PRT). We observed that an increase in the level of activity correlated with an increase of MWSS and a decrease of OSI at three locations in the abdominal aorta, and these changes were most significant below the renal arteries. As the level of activity increased, PRT in the aneurysm was significantly decreased: 50% of particles were cleared out of AAAs within 1.36 ± 0.43, 0.34 ± 0.10, and 0.22 ± 0.06 s at rest, mild exercise, and moderate exercise levels, respectively. Most of the reduction of PRT occurred from rest to the mild exercise level, suggesting that mild exercise may be sufficient to reduce flow stasis in AAAs.     

Patient-specific modelling of abdominal aortic aneurysms: The influence of wall thickness on predicted clinical outcomes

Rupture of abdominal aortic aneurysms (AAAs) is linked to aneurysm morphology. This study investigates the influence of patient-specific (PS) AAA wall thickness on predicted clinical outcomes. Eight patients under surveillance for AAAs were selected from the MA³RS clinical trial based on the complete absence of intraluminal thrombus. Two finite element (FE) models per patient were constructed; the first incorporated variable wall thickness from CT (PS_wall), and the second employed a 1.9 mm uniform wall (Uni_wall). Mean PS wall thickness across all patients was 1.77 ± 0.42 mm. Peak wall stress (PWS) for PS_wall and Uni_wall models was 0.6761 ± 0.3406 N/mm² and 0.4905 ± 0.0850 N/mm², respectively. In 4 out of 8 patients the Uni_wall underestimated stress by as much as 55%; in the remaining cases it overestimated stress by up to 40%. Rupture risk more than doubled in 3 out of 8 patients when PS_wall was considered. Wall thickness influenced the location and magnitude of PWS as well as its correlation with curvature. Furthermore, the volume of the AAA under elevated stress increased significantly in AAAs with higher rupture risk indices. This highlights the sensitivity of standard rupture risk markers to the specific wall thickness strategy employed.     

A Magnetic Approach to Decrease Stent Graft Endoleak: <Emphasis Type="Italic">Ex-Vivo</Emphasis> Validation

Stent graft endoleak is a major problem in endovascular aneurysm repair (EVAR). Endoleak occurs after EVAR and may lead to aneurysm rupture, acute vessel thrombosis or occlusion. This study presents a novel design to potentially reduce endoleak with use of magnets. A ferromagnetic stent is deployed into the vessel lumen, and two external flexible magnetic rings are used to clamp on the proximal and distal necks of the stent. The rings impose epivascular magnetic pressure on the vessel wall to prevent the vessel wall from separating from the stent under elevated blood pressure. The geometry and magnetic properties of the stent and rings were designed to produce sufficient pressure, without overly compressing the vessel wall. Feasibility of this design was demonstrated with in vitro experiments using porcine abdominal aortas. The experiments showed that magnetic ring significantly improved the seal between the stent and vessel wall with use of moderate-sized stent. For aortas subjected to physiological axial stretch, rings that generate magnetic pressure of about 45 mmHg were found sufficient to prevent endoleak at pressure of 140 mmHg. Evaluation of this design in an in vivo animal model of aortic aneurysm is warranted.     

Rapid platelet accumulation leading to thrombotic occlusion

Platelet thrombosis under arterial conditions remains a large clinical problem. Previous in vitro experiments have concentrated on early adherence without thrombotic occlusion. We have developed a controllable hemodynamic system that creates intravascular thrombosis to occlusion. Lightly heparinized (3.5 USP units/mL), whole, porcine blood is perfused through a 1.5 mm inner diameter, tubular, collagen-coated stenosis. The microscopic growth of thrombus is optically recorded using a high resolution CCD camera. Occlusive thrombus is examined using microcomputed tomography and histology. Thrombus consistently formed in the throat of the stenosis where wall shear rates were greatest. Rapid platelet accumulation (RPA) reached rates as high as 13.7 μm³ μm⁻² min⁻¹. Total occlusion of flow occurred after 17 ± 2.6 min (n = 6). The average thrombus volume accumulation of 7.8 ± 3.5 μm³ μm² min⁻¹ occurred under very high wall shear rates exceeding 100,000 s⁻¹. Significant volumes of thrombus did not form until 7.6 ± 3.6 min after the onset of flow, a delay consistent with activation of adherent mural platelets. Platelets did not accumulate with large volume for normal wall shear rates <2000 s⁻¹. Very high wall shear rates stimulate the capture of millions of circulating platelets with exposure times <2 ms in an arterial stenosis.     

A Numerical Implementation to Predict Residual Strains from the Homogeneous Stress Hypothesis with Application to Abdominal Aortic Aneurysms

Wall stress analysis of abdominal aortic aneurysm (AAA) is a promising method of identifying AAAs at high risk of rupture. However, neglecting residual strains (RS) in the load-free configuration of patient-specific finite element analysis models is a sever limitation that strongly affects the computed wall stresses. Although several methods for including RS have been proposed, they cannot be directly applied to patient-specific AAA simulations. RS in the AAA wall are predicted through volumetric tissue growth that aims at satisfying the homogeneous stress hypothesis at mean arterial pressure load. Tissue growth is interpolated linearly across the wall thickness and aneurysm tissues are described by isotropic constitutive formulations. The total deformation is multiplicatively split into elastic and growth contributions, and a staggered schema is used to solve the field variables. The algorithm is validated qualitatively at a cylindrical artery model and then applied to patient-specific AAAs (n = 5). The induced RS state is fully three-dimensional and in qualitative agreement with experimental observations, i.e., wall strips that were excised from the load-free wall showed stress-releasing-deformations that are typically seen in laboratory experiments. Compared to RS-free simulations, the proposed algorithm reduced the von Mises stress gradient across the wall by a tenfold. Accounting for RS leads to homogenized wall stresses, which apart from reducing the peak wall stress (PWS) also shifted its location in some cases. The present study demonstrated that the homogeneous stress hypothesis can be effectively used to predict RS in the load-free configuration of the vascular wall. The proposed algorithm leads to a fast and robust prediction of RS, which is fully capable for a patient-specific AAA rupture risk assessment. Neglecting RS leads to non-realistic wall stress values that severely overestimate the PWS.     

Tissue Responses to Endovascular Stent Grafts for Saccular Abdominal Aortic Aneurysms in a Canine Model

We investigated tissue responses to endoskeleton stent grafts for saccular abdominal aortic aneurysms (AAAs) in canines. Saccular AAAs were made with Dacron patch in 8 dogs, and were excluded by endoskeleton stent grafts composed of nitinol stent and expanded polytetrafluoroethylene graft. Animals were sacrificed at 2 months (Group 1; n = 3) or 6 months (Group 2; n = 5) after the placement, respectively. The aortas embedding stent grafts were excised en bloc for gross inspection and sliced at 5 to 8 mm intervals for histopathologic evaluation. Stent grafts were patent in all except a dog showing a thrombotic occlusion in Group 2. In the 7 dogs with patent lumen, the graft overhanging the saccular aneurysm was covered by thick or thin thrombi with no endothelial layer, and the graft over the aortic wall was completely covered by neointima with an endothelial layer. Transgraft cell migration was less active at an aneurysm than at adjacent normal aorta. In conclusion, endoskeleton stent grafts over saccular aneurysms show no endothelial coverage and poor transgraft cell migration in a canine model.     

In vivo feasibility case study for evaluating abdominal aortic aneurysm tissue properties and rupture potential using acoustic radiation force impulse imaging

An abdominal aortic aneurysm (AAA) is defined as a permanent and irreversible localized dilatation of the abdominal aorta. A reliable, non-invasive method to assess the wall mechanics of an aneurysm may provide additional information regarding their susceptibility to rupture. Acoustic radiation force impulse (ARFI) imaging is a phenomenon associated with the propagation of acoustic waves in attenuating media. This study was a preliminary evaluation to explore the feasibility of using ARFI imaging to examine an AAA in vivo. A previously diagnosed in vivo aneurysm case study was imaged to demonstrate the viability of excitation of the abdominal aorta using ARFI imaging. Ex vivo experiments were used to assess an artificially induced aneurysm to establish its development and whether ARFI was able to capture the mechanical changes during artificial aneurysm formation. A combination of in vivo and ex vivo results demonstrated a proposed hypothesis of estimation of the tissue's stiffness properties. The study details a method for non-invasive rupture potential prediction of AAAs using patient-specific moduli to generate a physiological stiffness rupture potential index (PSRPI) of the AAA. Clinical feasibility of ARFI imaging as an additional surgical tool to interrogate AAAs was verified and methods to utilize this data as a diagnostic tool was demonstrated with the PSRPI.     

The Role of Geometric and Biomechanical Factors in Abdominal Aortic Aneurysm Rupture Risk Assessment

The current clinical management of abdominal aortic aneurysm (AAA) disease is based to a great extent on measuring the aneurysm maximum diameter to decide when timely intervention is required. Decades of clinical evidence show that aneurysm diameter is positively associated with the risk of rupture, but other parameters may also play a role in causing or predisposing the AAA to rupture. Geometric factors such as vessel tortuosity, intraluminal thrombus volume, and wall surface area are implicated in the differentiation of ruptured and unruptured AAAs. Biomechanical factors identified by means of computational modeling techniques, such as peak wall stress, have been positively correlated with rupture risk with a higher accuracy and sensitivity than maximum diameter alone. The objective of this review is to examine these factors, which are found to influence AAA disease progression, clinical management and rupture potential, as well as to highlight on-going research by our group in aneurysm modeling and rupture risk assessment.     

Post-Treatment Hemodynamics of a Basilar Aneurysm and Bifurcation

To investigate whether or not a successful aneurysm treatment procedure can subject a parent artery to harmful hemodynamic stresses, computational fluid dynamics simulations are performed on a patient-specific basilar aneurysm and bifurcation before and after a virtual endovascular treatment. Prior to treatment, the aneurysm at systole is filled with a periodic train of vortex tubes, which form at the aneurysm neck and advect upwards into the dome. Following the treatment procedure however, the motion of the vortex train is inhibited by the aneurysm filling material, which confines the vortex tubes to the region beneath the aneurysm neck. Analysis of the post-treatment flow field indicates that the impingement of the basilar artery flow upon the treated aneurysm neck and the close proximity of a vortex tube to the parent artery wall increase the maximum wall shear stresses to values approximately equal to 50 Pa at systole. Calculation of the time-averaged wall shear stresses indicates that there is a 1.4 × 10⁻⁷ m² area on the parent artery exposed to wall shear stresses greater than 37.9 Pa, a value shown by Fry [Circ. Res. 22(2):165–197, 1968] to cause severe damage to the endothelial cells that line the artery wall. The results of this study demonstrate that it is possible for a treatment procedure, which successfully isolates the aneurysm from the circulation and leaves no aneurysm neck remnant, to elevate the hemodynamic stresses to levels that are injurious to the artery wall.     

Effects of blood flow and vessel geometry on wall stress and rupture risk of abdominal aortic aneurysms

Sudden rupture of abdominal aortic aneurysm (AAA), often without prior medical warning, is the 13th leading cause of mortality in the US. The local rupture is triggered when the elusive maximum local wall stress exceeds the patient's yield stress. Employing a validated fluid-structure interaction code, the coupled blood flow and AAA wall dynamics were simulated and analysed for two representative asymmetric AAAs with different neck angles and iliac bifurcations. It turned out that the AAA morphology plays an important role in wall deformation and stress distribution, and hence possible rupture. The neck angle substantially impacts flow fields. A large neck angle may cause strong irregular vortices in the AAA cavity and may influence the wall stress distribution remarkably. The rupture risk of lateral asymmetric AAAs is higher than for the anterior-posterior asymmetric types. The most likely rupture site is located near the anterior distal side for the anterior-posterior asymmetric AAA and the left distal side in the lateral asymmetric AAA.     

Mechanical properties of dilated human ascending aorta

Dilation of the ascending aorta, associated with Marfan Syndrome, bicuspid aortic valve, or advanced age, may lead to aortic dissection and rupture. Mathematical models can be used to assess the relative importance of increased wall stresses and decreased strength in these mechanical failures. To obtain needed inputs for such models, mechanical properties of dilated human ascending aorta were measured in vitro. Specimens for opening angle, biaxial elastic, and uniaxial circumferential strength tests were cut from excised tissue obtained from 54 patients (age 18–81 years) undergoing elective aortic graft replacement surgery. Opening angle was significantly greater in patients older than 50 years (262°±76°, n=21) compared to younger patients (202°±70°, n=13 All biaxial elastic specimens n=40 exhibited nonlinear stress-strain behavior. Rapid increases in circumferential and axial stresses occurred at lower strains in the older patient group than in the younger. Mean strength was significantly lower in older patients (1.35±0.37 MPa, n=14) than younger (2.04 ± 0.46 MPa, n=11, age <50 years). These changes in mechanical properties suggest that age may influence the risk of aortic dissection or rupture of dilated ascending aorta. © 2002 Biomedical Engineering Society. PAC2002: 8719Rr, 8719Hh     

MEMS thermal sensors to detect changes in heat transfer in the pre-atherosclerotic regions of fat-fed New Zealand white rabbits

Real-time detection of pre-atherosclerotic regions remains an unmet clinical challenge. We previously demonstrated the application of micro-electro-mechanical systems (MEMS) to detect changes in convective heat transfer in terms of sensor output voltages in the zone of flow reversal in an in vitro stenotic model. We hereby demonstrated changes in sensor output voltages in the pre-atherosclerotic regions in the New Zealand White rabbits fed on hypercholesterolemic diet (HD). After 8 weeks, we observed that mean output voltages (V _ave) were similar in the distal aortic arch, thoracic, and abdominal aortas in the normal standard diet (ND) group, consistent with an absence of atherosclerosis. In HD group, V _ave increased in the distal aortic arch (HD: V _ave = 1.05 ± 0.04 V; ND: V _ave = 0.12 ± 0.01 V, n = 3, p < 0.05) and in the thoracic aortas (HD: V _ave = 0.72 ± 0.06 V; ND: V _ave = 0.13 ± 0.024 V, n = 3, p < 0.05), consistent with the histological presence of pre-atherosclerosis. Despite HD diet, V _ave magnitudes were similar to ND group in the abdominal aortas (HD: V _ave = 0.14 ± 0.003 V; ND: V _ave = 0.14 ± 0.004 V, n = 3), corroborating histological absence of pre-atherosclerosis. Hence, MEMS thermal sensors provide a new approach to detect changes in convective heat transfer in the pre-atherosclerotic regions.     

Finite Element Modeling of Three-Dimensional Pulsatile Flow in the Abdominal Aorta: Relevance to Atherosclerosis

The infrarenal abdominal aorta is particularly prone to atherosclerotic plaque formation while the thoracic aorta is relatively resistant. Localized differences in hemodynamic conditions, including differences in velocity profiles, wall shear stress, and recirculation zones have been implicated in the differential localization of disease in the infrarenal aorta. A comprehensive computational framework was developed, utilizing a stabilized, time accurate, finite element method, to solve the equations governing blood flow in a model of a normal human abdominal aorta under simulated rest, pulsatile, flow conditions. Flow patterns and wall shear stress were computed. A recirculation zone was observed to form along the posterior wall of the infrarenal aorta. Low time-averaged wall shear stress and high shear stress temporal oscillations, as measured by an oscillatory shear index, were present in this location, along the posterior wall opposite the superior mesenteric artery and along the anterior wall between the superior and inferior mesenteric arteries. These regions were noted to coincide with a high probability-of-occurrence of sudanophilic lesions as reported by Cornhill et al. (Monogr. Atheroscler. 15:13--19, 1990). This numerical investigation provides detailed quantitative data on hemodynamic conditions in the abdominal aorta heretofore lacking in the study of the localization of atherosclerotic disease. © 1998 Biomedical Engineering Society. PAC98: 8745Hw, 0270Dh, 8710+e     

Changes of flow characteristics by stenting in aneurysm models: influence of aneurysm geometry and stent porosity

An endovascular technique using a stent has been developed and successfully applied in the treatment of wide neck aneurysms. A stent can facilitate thrombosis in the aneurysm pouch while maintaining biocompatible passage of the parent artery. Insertion of the stent changes the flow characteristics inside the aneurysm pouch, which can affect the intra-aneurysmal embolization process. The purpose of this study is to clarify the velocity and wall shear stress changes that are caused by stenting in fusiform and lateral aneurysm models. We used a flow visualization technique that incorporated a photochromic dye in order to observe the flow fields and measure the wall shear rates. The intra-aneurysmal flow motion was significantly reduced in the stented aneurysm models. Coherent inflow along the distal wall of the aneurysm was diminished and inflow was distributed along the pores of the stent wall in the stented models. Also, sluggish intra-aneurysmal vortex motion was well maintained in the stented aneurysm models during the deceleration phase. A less porous stent generally reduced the intraneurysmal fluid motion further, but the porosity effect was not significant. The magnitude and pulsatility of the wall shear rate were reduced by stenting, and the reductions were more significant in the lateral aneurysm models compared to the fusiform aneurysm models. The hemodynamic changes that were observed in our study can help explain the efficacy of in vivo thrombus formation caused by stenting. © 2002 Biomedical Engineering Society. PAC2002: 8719Uv, 8780-y, 8719Xx