Pulsatile flow: a critical modulator of the natural history of atherosclerosis

Numerical investigations of temperature and hemodynamics in carotid arteries with and without atherosclerotic plaque during open surgery

Intraoperative monitoring is essential for providing safe and effective care during open surgery. In this paper, numerical simulation is performed to track the flow and heat transfer of carotid arteries with and without atherosclerotic plaque in a real physiological system during surgery, in which the heat transport is first considered to couple to the blood flow due to the temperature dependence of the blood viscosity. The impacts of the operating room temperature and hematocrit (H) on the viscosity, velocity, temperature, wall shear stress (WSS), pressure drop and oscillation are investigated. The results demonstrate that the presence of plaque in the carotid artery induces a greater blood flow velocity, pressure drop, WSS, and oscillation, as well as a smaller viscosity and temperature variations. A decreasing ambient temperature leads to a decrease in the temperature and an increase in the low-WSS area, which implies a greater risk of hypothermia and atherosclerosis. As H increases, the high-WSS areas substantially expand; when H varies from 65% to 80%, WSS_ave increases by 70.02% and 68.57% for the arteries with and without plaque, respectively, which indicates a higher risk of vascular injury. The results obtained can serve as a guideline regarding the selection of an operating room temperature for carotid disease patients with distinct hematocrits.

Photoplethysmography and ultrasonic-measurement-integrated simulation to clarify the relation between two-dimensional unsteady blood flow field and forward and backward waves in a carotid artery

Understanding the spatiotemporal change in hemodynamics is essential for the basic research of atherosclerosis. The objective of this study was to establish a methodology to clarify the relation between a two-dimensional (2D) unsteady blood flow field and forward and backward propagating waves in a carotid artery. This study utilized photoplethysmography (PPG) for blood pressure measurement and two-dimensional ultrasonic-measurement-integrated (2D-UMI) simulation for flow field analysis. The validity of the methodology was confirmed in an experiment for a carotid artery of a healthy volunteer. Synchronization between the pressure measurement and flow field analysis was achieved with an error of <10 ms. A 2D unsteady blood flow field in the carotid artery was characterized in relation to forward and backward waves. 2D-UMI simulation reproduced the flow field in which the wall shear stress takes a maximum at the time of the backward wave superiority in the systolic phase, whereas 2D ordinary simulation failed to reproduce this feature because of poor reproducibility of velocity distribution. In conclusion, the proposed methodology using PPG and 2D-UMI simulation was shown to be a potential tool to clarify the relation between 2D unsteady blood flow field and the forward and backward waves in a carotid artery.

Fasudil, a Rho‑kinase inhibitor, prevents intima‑media thickening in a partially ligated carotid artery mouse model: Effects of fasudil in flow‑induced vascular remodeling

Vascular remodeling in response to hemodynamic alterations is a physiological process that requires coordinated signaling between endothelial, inflammatory and vascular smooth muscle cells (VSMCs). Extensive experimental and clinical studies have indicated the critical role of the Ras homolog gene family, member A/Rho‑associated kinase (ROCK) signaling pathway in the pathogenesis of cardiovascular disease, where ROCK activation has been demonstrated to promote inflammation and remodeling through inducing the expression of proinflammatory cytokines and adhesion molecules in endothelial cells and VSMCs. However, the role of ROCK in flow‑induced vascular remodeling has not been fully defined. The current study aimed to investigate the effect of the ROCK signaling pathway in flow‑induced vascular remodeling by comparing the responses to partial carotid artery ligation in mice treated with fasudil (a ROCK inhibitor) and untreated mice. Intima‑media thickness and neointima formation were evaluated by morphology. VSMC proliferation and inflammation of the vessel wall were assessed by immunohistochemistry. In addition, the expression levels of ROCK and the downstream effectors of ROCK, myosin light chain (MLC) and phosphorylated‑MLC (p‑MLC), were quantified by western blot analysis. Following a reduction in blood flow, ROCK1 and p‑MLC expression increased in the untreated left common carotid arteries (LCA). Fasudil‑treated mice developed a significantly smaller intima‑media thickness compared with the untreated mice. Quantitative immunohistochemistry of the fasudil‑treated LCA indicated that there was a reduction in proliferation when compared with untreated vessels. There were fewer CD45+ cells observed in the fasudil‑treated LCA compared with the untreated LCA. In conclusion, the expression of ROCK was enhanced in flow‑induced carotid artery remodeling and ROCK inhibition as a result of fasudil treatment may attenuate flow‑induced carotid artery remodeling.

Study of Estimation Method for Unsteady Inflow Velocity in Two-Dimensional Ultrasonic-Measurement-Integrated Blood Flow Simulation

Information on hemodynamics is essential for elucidation of mechanisms and development of novel diagnostic methods for circulatory diseases. Two-dimensional ultrasonic-measurement-integrated (2D-UMI) simulation can correctly reproduce an intravascular blood flow field and hemodynamics by feeding back an ultrasonic measurement to the numerical blood flow simulation. In this method, it is critically important to give the correct cross-sectional average inflow velocity (inflow velocity) as the boundary condition. However, systematic study has not been done on the relative validity and effectiveness of existing inflow velocity estimation methods for various target flow fields. The aim of this study was to examine the existing methods systematically and to establish a method to accurately estimate inflow velocities for various vessel geometries and flow conditions in 2D-UMI simulations. A numerical experiment was performed for 2D-UMI simulation of blood flow models in a straight vessel with inflow velocity profiles symmetric and asymmetric to the vessel axis using existing evaluation functions based on Doppler velocity error for the inflow velocity estimation. As a result, it was clarified that a significantly large estimation error occurs in the asymmetric flow due to a nonfeedback domain near the downstream end of the calculation domain. Hence, a new inflow velocity estimation method of 2D-UMI simulation is proposed in which the feedback and evaluation domains are extended to the downstream end. Further numerical experiments of 2D-UMI simulation for two realistic vessel geometries of a healthy blood vessel and a stenosed one confirmed the effectiveness of the proposed method.

The role of septal perforators and "myocardial bridging effect" in atherosclerotic plaque distribution in the coronary artery disease

The distribution of atherosclerotic plaque burden in the human coronary arteries is not uniform. Plaques are located mostly in the left anterior descending artery (LAD), then in the right coronary artery (RCA), circumflex branch (LCx) and the left main coronary artery (LM) in a decreasing order of frequency. In the LAD and LCx, plaques tend to cluster within the proximal segment, while in the RCA their distribution is more uniform. Several factors have been involved in this phenomenon, particularly flow patterns in the left and right coronary artery. Nevertheless, it does not explain the difference in lesion frequency between the LAD and the LCx as these are both parts of the left coronary artery. Branching points are considered to be the risk points of atherosclerosis. In the LCx, the number of side branches is lower than in the LAD or RCA and there are no septal perforators with intramuscular courses like in the proximal third of the LAD and the posterior descending artery (PDA). We hypothesized that septal branches generate disturbed flow in the LAD and PDA in a similar fashion to the myocardial bridge (myocardial bridging effect). This coronary architecture determines the non-uniform plaque distribution in coronary arteries and LAD predisposition to plaque formation.

Flow and atherosclerosis in coronary bifurcations

Coronary bifurcations are among the most frequent sites affected by atherosclerosis. In these regions, complex haemodynamic conditions prevail and local flow disturbances dictate the localisation and progression of atheroma. Endothelial shear stress (ESS) is the main flow-related factor affecting the distribution of atherosclerosis in a bifurcation. Plaques are more prevalent in low ESS areas, such as the lateral walls of the main vessel and side branches, while they are less common in the flow divider or carina, which is characterised by high ESS. However, the carina is not free of atheroma and is affected in up to one third of cases, but never in isolation. Lesions in the carina are likely to develop at a later stage of atherosclerosis, as result of circumferential expansion of plaques from the lateral wall. Pulsatile flow augments the local atherogenic environment by inducing low and oscillatory ESS. The geometrical configuration is also important as increased curvature and wide angles between the side branches of the bifurcation intensify flow perturbations, and highly curved segments show low ESS in the inner aspect of curvatures. Further research on the flow conditions which determine the initiation and progression of atherosclerosis in bifurcations will allow for more efficient prevention and management strategies.

Experimental investigation of the flow of a blood analogue fluid in a replica of a bifurcated small artery

The scope of this work is to study the pulsatile flow of a blood mimicking fluid in a micro channel that simulates a bifurcated small artery, in which the Fahraeus-Lindqvist effect is insignificant. An aqueous glycerol solution with small amounts of xanthan gum was used for simulating viscoelastic properties of blood and in vivo flow conditions were reproduced. Local flow velocities were measured using micro Particle Image Velocimetry (μ-PIV). From the measured velocity distributions, the wall shear stress (WSS) and its variation during a pulse were estimated. The Reynolds numbers employed are relatively low, i.e. similar to those prevailing during blood flow in small arteries. Experiments both with a Newtonian and a non-Newtonian fluid (having asymptotic viscosity equal to the viscosity of the Newtonian one) proved that the common assumption that blood behaves as a Newtonian fluid is not valid for blood flow in small arteries. It was also shown that the outer wall of the bifurcation, which is exposed to a lower WSS, is more predisposed to atherosclerotic plaque formation. Moreover, this region in small vessels is shorter than the one in large arteries, as the developed secondary flow decays faster. Finally, the WSS values in small arteries were found to be lower than those in large ones.

In-vivo assessment of the natural history of coronary atherosclerosis: vascular remodeling and endothelial shear stress determine the complexity of atherosclerotic disease progression

PURPOSE OF REVIEW

Atherosclerotic disease progression is determined by localized plaque growth, which is induced by systemic and local hemodynamic factors, and the nature of the wall remodeling response. The purpose of this review is to summarize the processes underlying the heterogeneity of coronary atherosclerosis progression in relation to the local hemodynamic and arterial remodeling environment.

RECENT FINDINGS

Multiple competing biological processes in the extracellular matrix define the extent of vascular remodeling and disease progression. The remodeling phenomenon is not consistent but is characterized by great phenotypical heterogeneity which reflects the complex effect of systemic, genetic and hemodynamic factors on the arterial wall response to plaque formation and progression. The exaggeration of expansive remodeling (i.e., excessive expansive remodeling) likely contributes to the transformation of an initially favorable action into an excessive course of vessel expansion, continued disease progression and plaque instability. Extremely low endothelial shear stress and excessive expansive remodeling establish a vicious cycle which leads to the formation of severe plaques with high-risk characteristics.

SUMMARY

The dynamic interplay between the local hemodynamic environment and the wall remodeling behavior determines the complexity of the natural history of atherosclerosis and explains the development of localized plaque vulnerability.

Difference in the topography of atherosclerosis in the left versus right coronary artery in patients referred for coronary angiography

Background

We sought to determine the difference in the localization of coronary artery disease (CAD) between the left and right coronary artery system and investigate the effect of sex and age on that difference.

Methods

We retrospectively analyzed 17,323 consecutive angiographies from January 1^st, 1984 to December 31^st, 2003. The demographic parameters, in particular age and sex of the investigated cases as well as the angiographic results were recorded and summarized.

Results

Of 13,305 cases with CAD, 861 (6.5%) had right coronary artery (RCA)-only disease, 4,621 (34.7%) had left coronary artery (LCA)-only disease, while 7,823 (58.8%) cases had concomitant RCA and LCA disease. LCA-only disease was more frequent than RCA-only disease [LCA-only/RCA-only odds ratio (OR): 5.37, 95% CI: 4.99 to 5.77, p < 0.001]. Women were more likely to have LCA-only disease (men/women OR 0.75 95% CI: 0.68 to 0.82, p < 0.001) compared with men who were more likely to present with concomitant RCA and LCA disease (men/women OR 1.33 95% CI: 1.21 to 1.45, p < 0.001). RCA-only and LCA-only disease were both more frequent in patients aged from 51 to 60 years, while concomitant RCA and LCA disease in patients between 61 and 70 years of age.

Conclusions

LCA-only disease is more frequent than RCA-only disease. Men have a higher probability than women to present with concomitant RCA and LCA disease while women are more likely than men to be found with LCA-only disease.

Myocardial bridges spared from atherosclerosis: overview of the underlying mechanisms

Myocardial bridging constitutes a congenital, usually benign, coronary abnormality defined as a segment of a major epicardial coronary artery that follows an intramural course through the myocardium. On the basis of clinical and histopathological data, myocardial bridges appear to be spared from atherosclerosis. Although the mechanisms involved are largely unknown, the surrounding myocardium appears to be a key factor by generating a unique atheroprotective hemodynamic microenvironment within bridges. The main components of this environment include low tensile stress and high shear stress. Reduced coronary wall motion due to external support of the surrounding myocardium may also play a role. Better investigation of these mechanisms in appropriate animal models is anticipated to advance our understanding of the pathophysiology of atherosclerosis, providing a framework for the development of new atheroprotective strategies.

Arterial geometry, flow pattern, wall shear and mass transport: potential physiological significance

We have studied numerically steady and unsteady flow in a straight and a helically stented common carotid artery, in order to model porcine experimental results that show reduced intimal hyperplasia (IH) in the helical case. The combination of flow pulsatility and three-dimensionality generates a sweeping motion of the Dean vortices, which overall reduced extremes of both oxygen flux to the vessel wall and wall shear stress (WSS). Since IH and atherosclerosis affect preferentially low WSS regions, these findings imply that vessel three-dimensionality and flow pulsatility can play important protective roles in respect of these diseases. The amplitude and frequency of the velocity waveform are important parameters of the system. Increase in amplitude increases WSS and oxygen flux to the vessel wall. Increase in frequency has a small effect; it increases WSS but has no effect on the oxygen flux to the vessel wall.

Heparin-binding epidermal growth factor-like growth factor signaling in flow-induced arterial remodeling

Heparin-binding epidermal growth factor (EGF)-like growth factor (HB-EGF) is activated by reduced endothelial shear stress and stimulates smooth muscle cell proliferation in vitro. Moreover, HB-EGF is augmented at sites of intimal hyperplasia and atherosclerosis, conditions favored by low/disturbed shear stress. We thus tested whether HB-EGF contributes to low flow-induced negative hypertrophic remodeling (FINR) of a mouse carotid artery. Blood flow was surgically decreased in the left and increased in the right common carotid arteries. After 21 days, the left carotid artery exhibited lumen narrowing, thickening of intima-media and adventitia, and increased circumference that were inhibited by approximately 50% in HB-EGF(+/-) and approximately 90% in HB-EGF(-/-) mice. FINR was also inhibited by the EGF receptor inhibitor AG1478. In contrast, eutrophic outward remodeling of the right carotid artery was unaffected in HB-EGF(+/-) and HB-EGF(-/-) mice, nor by AG1478. FINR-induced proliferation and leukocyte accumulation were reduced in HB-EGF(-/-). FINR was associated with increased reactive oxygen species, increased expression of pro-HB-EGF and tumor necrosis factor alpha-converting enzyme (pro-HB-EGF sheddase), increased phosphorylation of EGF receptor and extracellular signal-regulated kinase 1/2, and increased nuclear factor kappaB activity. Apocynin and deletion of p47(phox) inhibited FINR, whereas deletion of HB-EGF abolished nuclear factor kappaB activation in smooth muscle cells. These findings suggest that HB-EGF signaling is required for low flow-induced hypertrophic remodeling and may participate in vascular wall disease and remodeling.

Coronary hemodynamics and atherosclerotic wall stiffness: a vicious cycle

Local hemodynamic environment, including low shear stress and increased tensile stress, determines the localization, growth and progression of coronary atherosclerosis. As atherosclerotic lesions evolve, the diseased coronary arteries undergo local quantitative and qualitative changes in their wall, and progressively become stiff. Arterial stiffening amplifies the atherogenic local hemodynamic environment, initiating a self-perpetuating vicious cycle, which drives the progression of atherosclerosis and the formation of atherosclerotic plaque. In vivo evidence indicates that endothelial dysfunction is associated with arterial stiffness, an association that creates a challenging perspective of utilizing stiffness as an early marker of endothelial dysfunction and future atherosclerosis. Coronary stiffening is also associated with vascular remodeling, which is a major determinant of the natural history of atherosclerotic plaques. Thus, arterial stiffness may constitute a useful marker for the identification of the remodeling pattern, in particular expansive remodeling, which is closely associated with high-risk plaques. The early identification of endothelial dysfunction, or a high-risk plaque may enable the early adoption of preventive measures to improve endothelial function, or justify pre-emptive local interventions in high-risk regions to prevent future acute coronary syndromes. Further experimental and perspective clinical studies are needed for the investigation of these perspectives, whereas the development of new modalities for non-invasive and reliable assessment of coronary stiffness is anticipated to serve these studies.