Physical properties of tissues relevant to arterial ultrasound imaging and blood velocity measurement

Histotripsy and Catheter-Directed Lytic: Efficacy in Highly Retracted Porcine Clots In Vitro

OBJECTIVE

Standard treatment for deep vein thrombosis (DVT) involves catheter-directed anticoagulants or thrombolytics, but the chronic thrombi present in many DVT cases are often resistant to this therapy. Histotripsy has been found to be a promising adjuvant treatment, using the mechanical action of cavitating bubble clouds to enhance thrombolytic activity. The objective of this study was to determine if histotripsy enhanced recombinant tissue plasminogen activator (rt-PA) thrombolysis in highly retracted porcine clots in vitro in a flow model of occlusive DVT.

METHODS

Highly retracted porcine whole blood clots were treated for 1 h with either catheter-directed saline (negative control), rt-PA (lytic control), histotripsy, DEFINITY and histotripsy or the combination of rt-PA and histotripsy with or without DEFINITY. Five-cycle, 1.5 MHz histotripsy pulses with a peak negative pressure of 33.2 MPa and pulse repetition frequency of 40 Hz were applied along the clot. B-Mode and passive cavitation images were acquired during histotripsy insonation to monitor bubble activity.

RESULTS

Clots subjected to histotripsy with and without rt-PA exhibited greater thrombolytic efficacy than controls (7.0% flow recovery or lower), and histotripsy with rt-PA was more efficacious than histotripsy with saline (86.1 ± 10.2% compared with 61.7 ± 19.8% flow recovery). The addition of DEFINITY to histotripsy with or without rt-PA did not enhance either thrombolytic efficacy or cavitation dose. Cavitation dose generally did not correlate with thrombolytic efficacy.

CONCLUSION

Enhancement of thrombolytic efficacy was achieved using histotripsy, with and without catheter-directed rt-PA, in the presence of physiologic flow. This suggests these treatments may be effective as therapy for DVT.

Fabrication and Characterization of Tissue-Mimicking Phantoms for Ultrasound-Guided Cannulation Training

Tissue-mimicking materials (TMMs) have been investigated and used for decades as imaging phantoms in various medical applications. They are designed and fabricated to replicate certain biological tissue characteristics, a process often dictated by the target application. Moreover, TMMs have been utilized in some medical procedural training requiring the use of imaging modalities. One potential application for TMMs is ultrasound-guided cannulation training. Cannulation is a procedure that requires a level of dexterity to gain vascular access using ultrasound guidance while avoiding complications like vessel laceration and bleeding. However, an ideal phantom for this application is yet to be developed. This work investigates the development and characterization of high-fidelity phantoms for cannulation training. The mechanical (shore hardness, elastic modulus, and needle-interaction forces) and acoustic (B-mode ultrasound scans) properties of candidate materials were quantitatively compared with biological tissue. The evaluated materials included ballistic gel, plasticized polyvinyl chloride (PVC), silicone, gelatin, agar, and polyvinyl alcohol (PVA)- cryogel. Mechanical testing demonstrated that each material could replicate the Shore hardness and elasticity characteristics of different biological tissues (skin, fat, and muscle), with PVA and PVC showing tunability by varying composition or fabrication processes. Shore hardness (OO-range) for PVA ranged between 6.3 ± 1.0 to 59.3 ± 2.6 and PVC from 4.8 ± 0.7 to 14.6 ± 0.8. Ultrasound scans of PVA were the closest to human scans, both qualitatively (based on experts' opinion) and quantitatively (based on pixel intensity measurements). Modified mixtures of PVA are found to best serve as high-fidelity cannulation phantoms. Alternatively, PVC can be used to avoid troublesome fabrication processes of PVA.

A Review of Carotid Artery Phantoms for Doppler Ultrasound Applications

Ultrasound imaging systems need tissue-mimicking phantoms with a good range of acoustic properties. Many studies on carotid artery phantoms have been carried out using ultrasound; hence this study presents a review of the different forms of carotid artery phantoms used to examine blood hemodynamics by Doppler ultrasound (DU) methods and explains the ingredients that constitute every phantom with their advantages and disadvantages. Different research databases were consulted to access relevant information on carotid artery phantoms used for DU measurements after which the information were presented systematically spanning from walled phantoms to wall-less phantoms. This review points out the fact that carotid artery phantoms are made up of tissue mimicking materials, vessel mimicking materials, and blood mimicking fluid whose properties matched those of real human tissues and vessels. These materials are a combination of substances such as water, gelatin, glycerol, scatterers, and other powders in their right proportions.

4D Reconstruction and Identification of Carotid Artery Stenosis Utilizing a Novel Pulsatile Ultrasound Phantom

As a major application focus of vascular ultrasonography, the carotid artery has long been the subject of phantom design and procedure focus. It is therefore important to devise procedures that are minimally invasive and informative, initially using a physiologically accurate anthropomorphic phantom to validate the methodology. In this article, a novel phantom design protocol is presented that enables the efficient production of a pulsatile ultrasound phantom consisting of soft and vascular tissue mimics, as well as a blood surrogate fluid. These components when combined give the phantom high acoustic compatibility and lifelike mechanical properties. The phantom was developed using "at-home" purchasable components and 3D printing technology. The phantom was subsequently used to develop a 4D reconstruction algorithm of the pulsing vessel in MATLAB. In pattern with recent developments in medical imaging, the 4D reconstruction enables clinicians to view vessel wall motion in a 3D space without the need for manual intervention. The reconstruction algorithm also produces measured inner luminal areas and vessel wall thickness, providing further information relating to structural properties and stenosis, as well as elastic properties such as arterial stiffness, which could provide helpful markers for disease diagnosis. © 2021 Wiley Periodicals LLC. Basic Protocol 1: Constructing a pulsatile ultrasound phantom model Support Protocol: Creating a vascular mimic mold Basic Protocol 2: Creating a 4D reconstruction from ultrasound frames.

Vein wall shrinkage induced by thermal coagulation with high-intensity-focused ultrasound: numerical modeling and in vivo experiments in sheep

BACKGROUND

Varicose veins are a common disease that may significantly affect quality of life. Different approaches are currently used in clinical practice to treat this pathology.

MATERIALS AND METHODS

In thermal therapy (radiofrequency or laser therapy), the vein is directly heated to a high temperature to induce vein wall coagulation, and the heat induces denaturation of the intramural collagen, which results macroscopically in vein shrinkage. Thermal vein shrinkage is a physical indicator of the efficiency of endovenous treatment. High-intensity focused ultrasound (HIFU) is a noninvasive technique that can thermally coagulate vein walls and induce vein shrinkage. In this study, we evaluated the vein shrinkage induced in vivo by extracorporeal HIFU ablation of sheep veins: six lateral saphenous veins (3.4mm mean diameter) were sonicated for 8 s with 3MHz continuous waves. Ultrasound imaging was performed before and immediately post-HIFU to quantify the HIFU-induced shrinkage.

RESULTS

Luminal constriction was observed in 100% (6/6) of the treated veins. The immediate findings showed a mean diameter constriction of 53%. The experimental HIFU-induced shrinkage data were used to validate a numerical model developed to predict the thermally induced vein contraction during HIFU treatment.

CONCLUSIONS

This model is based on the use of the k-wave library and published contraction rates of vessels immersed in hot water baths. The simulation results agreed well with those of in vivo experiments, showing a mean percent difference of 5%. The numerical model could thus be a valuable tool for optimizing ultrasound parameters as functions of the vein diameter, and future clinical trials are anticipated.

A Polyvinyl Alcohol-Based Thermochromic Material for Ultrasound Therapy Phantoms

Temperature estimation is a fundamental step in assessment of the efficacy of thermal therapy. A thermochromic material sensitive within the temperature range 52.5°C-75°C has been developed. The material is based on polyvinyl alcohol cryogel with the addition of a commercial thermochromic ink. It is simple to manufacture, low cost, non-toxic and versatile. The thermal response of the material was evaluated using multiple methods, including immersion in a temperature-controlled water bath, a temperature-controlled heated needle and high-intensity focused ultrasound (HIFU) sonication. Changes in colour were evaluated using both RGB (red, green, blue) maps and pixel intensities. Acoustic and thermal properties of the material were measured. Thermo-acoustic simulations were run with an open-source software, and results were compared with the HIFU experiments, showing good agreement. The material has good potential for the development of ultrasound therapy phantoms.

Walled vessel-mimicking phantom for ultrasound imaging using 3D printing with a water-soluble filament: design principle, fluid-structure interaction (FSI) simulation, and experimental validation

The geometry and stiffness of a vessel are pertinent to blood dynamics and vessel wall mechanical behavior and may alter in diseased conditions. Ultrasound-based ultrafast Doppler (uDoppler) imaging and shear wave imaging (SWI) techniques have been extensively exploited for the assessment of vascular hemodynamics and mechanics. Their performance is conventionally validated on vessel-mimicking phantoms (VMPs) prior to their clinical use. Compared with commercial ones, customized VMPs are favored for research use because of their wider range of material properties, more complex lumen geometries, or wall structures. Fused deposition modeling (FDM) 3D printing technique with plastic filaments is a promising method for making VMPs with a complex vessel lumen. However, it may require a toxic solvent or a long dissolution time currently. In this paper, we present a safe, efficient and geometrically flexible method where FDM 3D printing with a water-soluble polyvinyl alcohol (PVA) filament is exploited to fabricate a walled three-branch VMP (VMP-I). As a key step in fabrication, to avoid dissolution of the PVA-printed vessel core by the solution of the tissue-mimicking material, paraffin wax was used for isolation. Paraffin wax is easy to coat (i.e. without any special equipment), of satisfactory thickness (∼0.1 mm), chemically stable, and easy to remove after fabrication, thus making the proposed method practicable for ultrasound imaging studies. VMP-I was examined by B-mode imaging and power Doppler imaging (PDI) to verify complete dissolution of PVA-printed vessel core in its lumen, confirming good fabrication quality. The flow velocities in VMP-I were estimated by uDoppler imaging with a -0.8% difference, and the shear wave propagation speeds for the same phantom were estimated by SWI with a -6.03% difference when compared with fluid-structure interaction (FSI) simulation results. A wall-less VMP of a scaled and simplified coronary arterial network (VMP-II) was additionally fabricated and examined to test the capability of the proposed method for a complex lumen geometry. The proposed fabrication method for customized VMPs is foreseen to facilitate the development of ultrasound imaging techniques for blood vessels.

Modeling tissue-selective cavitation damage

The destructive growth and collapse of cavitation bubbles are used for therapeutic purposes in focused ultrasound procedures and can contribute to tissue damage in traumatic injuries. Histotripsy is a focused ultrasound procedure that relies on controlled cavitation to homogenize soft tissue. Experimental studies of histotripsy cavitation have shown that the extent of ablation in different tissues depends on tissue mechanical properties and waveform parameters. Variable tissue susceptibility to the large stresses, strains, and strain rates developed by cavitation bubbles has been suggested as a basis for localized liver tumor treatments that spare large vessels and bile ducts. However, field quantities developed within microns of cavitation bubbles are too localized and transient to measure in experiments. Previous numerical studies have attempted to circumvent this challenge but made limited use of realistic tissue property data. In this study, numerical simulations are used to calculate stress, strain, and strain rate fields produced by bubble oscillation under histotripsy forcing in a variety of tissues with literature-sourced viscoelastic and acoustic properties. Strain field calculations are then used to predict a theoretical damage radius using tissue ultimate strain data. Simulation results support the hypothesis that differential tissue responses could be used to design tissue-selective treatments. Results agree with studies correlating tissue ultimate fractional strain with resistance to histotripsy ablation and are also consistent with experiments demonstrating smaller lesion size under exposure to higher frequency waveforms. Methods presented in this study provide an approach for modeling tissue-selective cavitation damage in general.

The effects of ultrasound parameters and microbubble concentration on acoustic particle palpation

The elasticity of tissue-an indicator of disease progression-can be imaged by ultrasound elasticity imaging technologies. An acoustic particle palpation (APP) has recently been developed-the use of ultrasonically driven acoustic particles (e.g., microbubbles)-as an alternative method of tissue deformation. APP has the potential to improve the resolution, contrast, and depth of ultrasound elasticity imaging; but the tissue displacement dynamics and its dependence on acoustic pressure, center frequency, and microbubble concentration remains unknown. Here, displacements of at least 1 μm were produced by applying ultrasound onto a microbubble solution (concentration: 10 × 10⁶ microbubbles ml^-1) placed within a tunnel surrounded by a 5% gelatin phantom. Displacements of more than 10 μm were produced using a 1, 3.5, or 5 MHz center frequency pulse with peak-rarefactional pressures of 470, 785, and 1210 kPa, respectively. The deformation of the distal wall varied spatially and temporally according to the different parameters investigated. At low pressures, the deformation increased over several milliseconds until it was held at a nearly constant value. At high pressures, a large deformation occurred within a millisecond followed by a sharp decrease and long stabilization. Ultrasound exposure in the presence of microbubbles produced tissue deformation (p < 0.05) while without microbubbles, no deformation was observed.

Automatic Early-Onset Free Flap Failure Detection for Implantable Biomedical Devices

OBJECTIVE

Up to 10% of free flap cases are compromised, and without prompt intervention, amputation and even death can occur. Hourly monitoring improves salvage rates, but the gold standard for monitoring requires experienced personnel to operate and suffers from high false-positive rates as high as 31% that result in costly and unnecessary surgeries. In this paper, we investigate free flap patency monitoring using automatic hardware-only classification systems that eliminate the need for experienced personnel. The expected flow ranges of the antegrade and retrograde veins for breast reconstruction are studied using a syringe pump to create the laminar flow seen in veins.

METHODS

Feature data extracted from the Doppler blood flow signals are analyzed for sensitivity, specificity, and false-positive rates. Hardware is built to perform the classification automatically in real-time and output a decision at the end of the observation period.

RESULTS

Experimental results using the hardware-only classifier for a 50 ms window size show high sensitivity (96.75%), specificity (90.20%), and low false-positive rate (9.803%). The experimental and theoretical classification results show close agreement.

CONCLUSION

This work indicates that automatic hardware-only classifiers can eliminate the need for experienced personnel to monitor free flap patency.

SIGNIFICANCE

The hardware-only classification is amenable to a monolithic implementation and future studies should study a totally implantable wirelessly-powered blood flow classifier. The high classifier performance in a short window period indicates that duty-cycled powering can be used to extend the safe operational depth of an implant. This is particularly relevant for the difficult buried free flap applications.

Thermal characteristics of non-biological vessel phantoms for treatment of varicose veins using high-intensity focused ultrasound

The ultrasonic treatment of varicose veins uses high-intensity focused ultrasound, in which a blood vessel is contracted by converting acoustic energy into thermal energy. In this study, we propose a phantom of varicose veins that can be applied for the efficient evaluation of ultrasonic treatment in varicose veins. The proposed phantom consisted of glycerol base tissue equivalent material, vessel mimic tube, and blood mimic substances. The vessel mimic tube was placed inner glycerol phantom and it was filled with blood mimic substances. Blood-mimicked substances are prepared by adjusting the concentration of the glycerol solution to be similar to the acoustic properties of the blood, and vessel-mimicking materials are selected by measuring acoustic properties and thermal shrinkage of various materials in a heat-shrinkable tube. The blood vessels surrounding the tissue are replaced with the phantom similar to glycerol-based organization, and venous blood flow is implemented using a DC motor. The heating characteristics according to the ultrasonic wave using the manufactured varicose veins phantom were evaluated. As the sound wave irradiation time and power increased, the contractility of the vessel mimicking materials and the temperature of the surrounding tissues were increased. When the blood-mimicking material was circulated, the highest temperature in the focused region and the contractility of vessel mimicking materials were reduced under the same conditions as used for sonication. The manufactured phantom may contribute to the treatment of varicose veins and can be used to predict the ultrasonic therapeutic efficiency of varicose veins.

Totally Implantable Wireless Ultrasonic Doppler Blood Flowmeters: Toward Accurate Miniaturized Chronic Monitors

Totally implantable wireless ultrasonic blood flowmeters provide direct-access chronic vessel monitoring in hard-to-reach places without using wired bedside monitors or imaging equipment. Although wireless implantable Doppler devices are accurate for most applications, device size and implant lifetime remain vastly underdeveloped. We review past and current approaches to miniaturization and implant lifetime extension for wireless implantable Doppler devices and propose approaches to reduce device size and maximize implant lifetime for the next generation of devices. Additionally, we review current and past approaches to accurate blood flow measurements. This review points toward relying on increased levels of monolithic customization and integration to reduce size. Meanwhile, recommendations to maximize implant lifetime should include alternative sources of power, such as transcutaneous wireless power, that stand to extend lifetime indefinitely. Coupling together the results will pave the way for ultra-miniaturized totally implantable wireless blood flow monitors for truly chronic implantation.

Wall-Less Flow Phantoms With Tortuous Vascular Geometries: Design Principles and a Patient-Specific Model Fabrication Example

Flow phantoms with anatomically realistic geometry and high acoustic compatibility are valuable investigative tools in vascular ultrasound studies. Here, we present a new framework to fabricate ultrasound-compatible flow phantoms to replicate human vasculature that is tortuous, nonplanar, and branching in nature. This framework is based upon the integration of rapid prototyping and investment casting principles. A pedagogical walkthrough of our engineering protocol is presented in this paper using a patient-specific cerebral aneurysm model as an exemplar demonstration. The procedure for constructing the flow circuit component of the phantoms is also presented, including the design of a programmable flow pump system, the fabrication of blood mimicking fluid, and flow rate calibration. Using polyvinyl alcohol cryogel as the tissue mimicking material, phantoms developed with the presented protocol exhibited physiologically relevant acoustic properties [attenuation coefficient: 0.229±0.032 dB/( [Formula: see text]) and acoustic speed: 1535±2.4 m/s], and their pulsatile flow dynamics closely resembled the flow profile input. As a first application of our developed phantoms, the flow pattern of the patient-specific aneurysm model was visualized by performing high-frame-rate color-encoded speckle imaging over multiple time-synchronized scan planes. Persistent recirculation was observed, and the vortex center was found to shift in position over a cardiac cycle, indicating the 3-D nature of flow recirculation inside an aneurysm. These findings suggest that phantoms produced from our reported protocol can serve well as acoustically compatible test beds for vascular ultrasound studies, including 3-D flow imaging.

Walled Carotid Bifurcation Phantoms for Imaging Investigations of Vessel Wall Motion and Blood Flow Dynamics

As a major application domain of vascular ultrasound, the carotid artery has long been the subject of anthropomorphic phantom design. It is nevertheless not trivial to develop walled carotid phantoms that are compatible for use in integrative imaging of carotid wall motion and flow dynamics. In this paper, we present a novel phantom design protocol that can enable efficient fabrication of walled carotid bifurcation phantoms with: (i) high acoustic compatibility, (ii) artery-like vessel elasticity, and (iii) stenotic narrowing feature. Our protocol first involved direct fabrication of the vessel core and an outer mold using computer-aided design tools and 3-D printing technology; these built parts were then used to construct an elastic vessel tube through investment casting of a polyvinyl alcohol containing mixture, and an agar-gelatin tissue mimicking slab was formed around the vessel tube. For demonstration, we applied our protocol to develop a set of healthy and stenosed (25%, 50%, 75%) carotid bifurcation phantoms. Plane wave imaging experiments were performed on these phantoms using an ultrasound scanner with channel-level configurability. Results show that the wall motion dynamics of our phantoms agreed with pulse wave propagation in an elastic vessel (pulse wave velocity of 4.67±0.71 m/s measured at the common carotid artery), and their flow dynamics matched the expected ones in healthy and stenosed bifurcation (recirculation and flow jet formation observed). Integrative imaging of vessel wall motion and blood flow dynamics in our phantoms was also demonstrated, from which we observed fluid-structure interaction differences between healthy and diseased bifurcation phantoms. These findings show that the walled bifurcation phantoms developed with our new protocol are useful in vascular imaging studies that individually or jointly assess wall motion and flow dynamics.

FloWave.US: validated, open-source, and flexible software for ultrasound blood flow analysis

Automated software improves the accuracy and reliability of blood velocity, vessel diameter, blood flow, and shear rate ultrasound measurements, but existing software offers limited flexibility to customize and validate analyses. We developed FloWave.US-open-source software to automate ultrasound blood flow analysis-and demonstrated the validity of its blood velocity (aggregate relative error, 4.32%) and vessel diameter (0.31%) measures with a skeletal muscle ultrasound flow phantom. Compared with a commercial, manual analysis software program, FloWave.US produced equivalent in vivo cardiac cycle time-averaged mean (TAMean) velocities at rest and following a 10-s muscle contraction (mean bias <1 pixel for both conditions). Automated analysis of ultrasound blood flow data was 9.8 times faster than the manual method. Finally, a case study of a lower extremity muscle contraction experiment highlighted the ability of FloWave.US to measure small fluctuations in TAMean velocity, vessel diameter, and mean blood flow at specific time points in the cardiac cycle. In summary, the collective features of our newly designed software-accuracy, reliability, reduced processing time, cost-effectiveness, and flexibility-offer advantages over existing proprietary options. Further, public distribution of FloWave.US allows researchers to easily access and customize code to adapt ultrasound blood flow analysis to a variety of vascular physiology applications.

Efficacy of histotripsy combined with rt-PA in vitro

Histotripsy, a form of therapeutic ultrasound that uses the mechanical action of microbubble clouds for tissue ablation, is under development to treat chronic deep vein thrombosis (DVT). We hypothesize that combining thrombolytic agents with histotripsy will enhance clot lysis. Recombinant tissue plasminogen activator (rt-PA) and rt-PA-loaded echogenic liposomes that entrain octafluoropropane microbubbles (OFP t-ELIP) were used in combination with highly shocked histotripsy pulses. Fully retracted porcine venous clots, with similar features of DVT occlusions, were exposed either to histotripsy pulses alone (peak negative pressures of 7-20 MPa), histotripsy and OFP t-ELIP, or histotripsy and rt-PA. Microbubble cloud activity was monitored with passive cavitation imaging during histotripsy exposure. The power levels of cavitation emissions from within the clot were not statistically different between treatment types, likely due to the near instantaneous rupture and destruction of OFP t-ELIP. The thrombolytic efficacy was significantly improved in the presence of rt-PA. These results suggest the combination of histotripsy and rt-PA could serve as a potent therapeutic strategy for the treatment of DVT.

The simulation of magnetic resonance elastography through atherosclerosis

The clinical diagnosis of atherosclerosis via the measurement of stenosis size is widely acknowledged as an imperfect criterion. The vulnerability of an atherosclerotic plaque to rupture is associated with its mechanical properties. The potential to image these mechanical properties using magnetic resonance elastography (MRE) was investigated through synthetic datasets. An image of the steady state wave propagation, equivalent to the first harmonic, can be extracted directly from finite element analysis. Inversion of this displacement data yields a map of the shear modulus, known as an elastogram. The variation of plaque composition, stenosis size, Gaussian noise, filter thresholds and excitation frequency were explored. A decreasing mean shear modulus with an increasing lipid composition was identified through all stenosis sizes. However the inversion algorithm showed sensitivity to parameter variation leading to artefacts which disrupted both the elastograms and quantitative trends. As noise was increased up to a realistic level, the contrast was maintained between the fully fibrous and lipid plaques but lost between the interim compositions. Although incorporating a Butterworth filter improved the performance of the algorithm, restrictive filter thresholds resulted in a reduction of the sensitivity of the algorithm to composition and noise variation. Increasing the excitation frequency improved the techniques ability to image the magnitude of the shear modulus and identify a contrast between compositions. In conclusion, whilst the technique has the potential to image the shear modulus of atherosclerotic plaques, future research will require the integration of a heterogeneous inversion algorithm.

Comparison of vortical structures induced by arteriovenous grafts using vector Doppler ultrasound

Arteriovenous prosthetic grafts are used in hemodialysis. Stenosis in the venous anastomosis is the main cause of occlusion and the role of local hemodynamics in this is considered significant. A new spiral graft design has been proposed to stabilize the flow phenomena in the host vein. Cross-flow vortical structures in the outflow of this graft were compared with those from a control device. Both grafts were integrated in identical in-house ultrasound-compatible flow phantoms with realistic surgical configurations. Constant flow rates were applied. In-plane 2-D velocity and vorticity mapping was developed using a vector Doppler technique. One or two vortices were detected for the spiral graft and two to four for the control, along with reduced stagnation points for the former. The in-plane peak velocity and circulation were calculated and found to be greater for the spiral device, implying increased in-plane mixing, which is believed to inhibit thrombosis and neo-intimal hyperplasia.

Blood flow in intracranial aneurysms treated with Pipeline embolization devices: computational simulation and verification with Doppler ultrasonography on phantom models

Purpose:

The aim of this study was to validate a computational fluid dynamics (CFD) simulation of flow-diverter treatment through Doppler ultrasonography measurements in patient-specific models of intracranial bifurcation and side-wall aneurysms.

Methods:

Computational and physical models of patient-specific bifurcation and sidewall aneurysms were constructed from computed tomography angiography with use of stereolithography, a three-dimensional printing technology. Flow dynamics parameters before and after flow-diverter treatment were measured with pulse-wave and color Doppler ultrasonography, and then compared with CFD simulations.

Results:

CFD simulations showed drastic flow reduction after flow-diverter treatment in both aneurysms. The mean volume flow rate decreased by 90% and 85% for the bifurcation aneurysm and the side-wall aneurysm, respectively. Velocity contour plots from computer simulations before and after flow diversion closely resembled the patterns obtained by color Doppler ultrasonography.

Conclusion:

The CFD estimation of flow reduction in aneurysms treated with a flow-diverting stent was verified by Doppler ultrasonography in patient-specific phantom models of bifurcation and side-wall aneurysms. The combination of CFD and ultrasonography may constitute a feasible and reliable technique in studying the treatment of intracranial aneurysms with flow-diverting stents.

A review of Doppler ultrasound quality assurance protocols and test devices

In this paper, an overview of Doppler ultrasound quality assurance (QA) testing will be presented in three sections. The first section will review the different Doppler ultrasound parameters recommended by professional bodies for use in QA protocols. The second section will include an evaluation and critique of the main test devices used to assess Doppler performance, while the final section of this paper will discuss which of the wide range of test devices have been found to be most suitable for inclusion in Doppler QA programmes. Pulsed Wave Spectral Doppler, Colour Doppler Imaging QA test protocols have been recommended over the years by various professional bodies, including the UK's Institute of Physics and Engineering in Medicine (IPEM), the American Institute for Ultrasound in Medicine (AIUM), and the International Electrotechnical Commission (IEC). However, despite the existence of such recommended test protocols, very few commercial or research test devices exist which can measure the full range of both PW Doppler ultrasound and colour Doppler imaging performance parameters, particularly quality control measurements such as: (i) Doppler sensitivity (ii) colour Doppler spatial resolution (iii) colour Doppler temporal resolution (iv) colour Doppler velocity resolution (v) clutter filter performance and (vi) tissue movement artefact suppression. In this review, the merits of the various commercial and research test devices will be considered and a summary of results obtained from published studies which have made use of some of these Doppler test devices, such as the flow, string, rotating and belt phantom, will be presented.

3D-Printed Tissue-Mimicking Phantoms for Medical Imaging and Computational Validation Applications

Abdominal aortic aneurysm (AAA) is a permanent, irreversible dilation of the distal region of the aorta. Recent efforts have focused on improved AAA screening and biomechanics-based failure prediction. Idealized and patient-specific AAA phantoms are often employed to validate numerical models and imaging modalities. To produce such phantoms, the investment casting process is frequently used, reconstructing the 3D vessel geometry from computed tomography patient scans. In this study the alternative use of 3D printing to produce phantoms is investigated. The mechanical properties of flexible 3D-printed materials are benchmarked against proven elastomers. We demonstrate the utility of this process with particular application to the emerging imaging modality of ultrasound-based pulse wave imaging, a noninvasive diagnostic methodology being developed to obtain regional vascular wall stiffness properties, differentiating normal and pathologic tissue in vivo. Phantom wall displacements under pulsatile loading conditions were observed, showing good correlation to fluid-structure interaction simulations and regions of peak wall stress predicted by finite element analysis. 3D-printed phantoms show a strong potential to improve medical imaging and computational analysis, potentially helping bridge the gap between experimental and clinical diagnostic tools.

Design of anthropomorphic flow phantoms based on rapid prototyping of compliant vessel geometries

Anatomically realistic flow phantoms are essential experimental tools for vascular ultrasound. Here we describe how these flow phantoms can be efficiently developed via a rapid prototyping (RP) framework that involves direct fabrication of compliant vessel geometries. In this framework, anthropomorphic vessel models were drafted in computer-aided design software, and they were fabricated using stereolithography (one type of RP). To produce elastic vessels, a compliant photopolymer was used for stereolithography. We fabricated a series of compliant, diseased carotid bifurcation models with eccentric stenosis (50%) and plaque ulceration (types I and III), and they were used to form thin-walled flow phantoms by coupling the vessels to an agar-based tissue-mimicking material. These phantoms were found to yield Doppler spectrograms with significant spectral broadening and color flow images with mosaic patterns, as typical of disturbed flow under stenosed and ulcerated disease conditions. Also, their wall distension behavior was found to be similar to that observed in vivo, and this corresponded with the vessel wall's average elastic modulus (391 kPa), which was within the nominal range for human arteries. The vessel material's acoustic properties were found to be sub-optimal: the estimated average acoustic speed was 1801 m/s, and the attenuation coefficient was 1.58 dB/(mm·MHz(n)) with a power-law coefficient of 0.97. Such an acoustic mismatch nevertheless did not notably affect our Doppler spectrograms and color flow image results. These findings suggest that phantoms produced from our design framework have the potential to serve as ultrasound-compatible test beds that can simulate complex flow dynamics similar to those observed in real vasculature.

High-frame-rate ultrasound color-encoded speckle imaging of complex flow dynamics

Realization of flow imaging at high frame rates is essential to the visualization of complex flow patterns with fast-changing spatiotemporal dynamics. In this study, we present an experimental demonstration of a novel ultrasound-based high-frame-rate flow visualization technique called color-encoded speckle imaging (CESI), which depicts flow information in a hybrid form comprising flow speckle pattern and color-encoded velocity mapping. This technique works by integrating two key principles: (i) using broad-view data acquisition schemes like plane wave compounding to obtain image data at frame rates well beyond the video display range and (ii) deriving and displaying both flow speckles and velocity estimates from the acquired broad-view image data. CESI was realized on a channel-domain ultrasound imaging research platform, and its performance was evaluated in the context of monitoring complex flow dynamics inside a carotid bifurcation flow phantom with 25% eccentric stenosis at the inlet of the internal carotid artery. Results show that, using an imaging frame rate of 2000 frames per second (based on plane wave compounding with five steering angles), CESI can effectively render flow acceleration and deceleration with visual continuity. It is also effective in depicting how stenosis-related flow disturbance events, such as flow jet formation and post-stenotic flow recirculation, evolve spatiotemporally over a pulse cycle. We anticipate that CESI can represent a rational approach to rendering flow information in ultrasound-based vascular diagnoses.

Development of a flexible implantable sensor for postoperative monitoring of blood flow

We have developed a blood flow measurement system using Doppler ultrasound flow sensors fabricated of thin and flexible piezoelectric-polymer films. These flow sensors can be wrapped around a blood vessel and accurately measure flow. The innovation that makes this flow sensor possible is the diffraction-grating transducer. A conventional transducer produces a sound beam perpendicular to its face; therefore, when placed on the wall of a blood vessel, the Doppler shift in the backscattered ultrasound from blood theoretically would be 0. The diffraction-grating transducer produces a beam at a known angle to its face; therefore, backscattered ultrasound from the vessel will contain a Doppler signal. Flow sensors were fabricated by spin coating a poly(vinylidene fluoride-trifluoroethylene) copolymer film onto a flexible substrate with patterned gold electrodes. Custom-designed battery-operated continuous wave Doppler electronics along with a laptop computer completed the system. A prototype flow sensor was evaluated experimentally by measuring blood flow in a flow phantom and the infrarenal aorta of an adult New Zealand White rabbit. The flow phantom experiment demonstrated that the error in average velocity and volume blood flow was less than 6% for 30 measurements taken over a 2.5-hour period. The peak blood velocity through the rabbit infrarenal aorta measured by the flow sensor was 118 cm/s, within 1.7% of the measurement obtained using a duplex ultrasound system. The flow sensor and electronics operated continuously during the course of the 5-hour experiment after the incision on the animal was closed.

Acoustic radiation force impulse imaging of vulnerable plaques: a finite element method parametric analysis

Plaque rupture is the most common cause of complications such as stroke and coronary heart failure. Recent histopathological evidence suggests that several plaque features, including a large lipid core and a thin fibrous cap, are associated with plaques most at risk for rupture. Acoustic Radiation Force Impulse (ARFI) imaging, a recently developed ultrasound-based elasticity imaging technique, shows promise for imaging these features noninvasively. Clinically, this could be used to distinguish vulnerable plaques, for which surgical intervention may be required, from those less prone to rupture. In this study, a parametric analysis using Finite Element Method (FEM) models was performed to simulate ARFI imaging of five different carotid artery plaques across a wide range of material properties. It was demonstrated that ARFI imaging could resolve the softer lipid pool from the surrounding, stiffer media and fibrous cap and was most dependent upon the stiffness of the lipid pool component. Stress concentrations due to an ARFI excitation were located in the media and fibrous cap components. In all cases, the maximum Von Mises stress was<1.2 kPa. In comparing these results with others investigating plaque rupture, it is concluded that while the mechanisms may be different, the Von Mises stresses imposed by ARFI imaging are orders of magnitude lower than the stresses associated with blood pressure.

Microfluidic system for simultaneous optical measurement of platelet aggregation at multiple shear rates in whole blood

Thrombosis is the pathological formation of platelet aggregates which occlude blood flow causing stroke and heart attack-the leading causes of death in developed nations. Instrumentation for diagnosing and exploring treatments for pathological platelet aggregation thus has the potential for major clinical impact. Most current thrombosis methods focus on single flow conditions, non-occlusive platelet adhesion, or low shear rates and so are limited in their application to comparative studies involving multiple, pathological test conditions (e.g., shear rate, stenotic geometries that mimic arteries, and rapid platelet accumulation to occlusion). The field could benefit from a low volume, high throughput, short analysis time, and low cost system while minimizing sample handling. We report on the design, fabrication, testing, and application of a microfluidic device and associated optical system for simultaneous measurement of platelet aggregation at multiple initial shear rates within four stenotic channels in label-free whole blood. Following computational design, requisite shear rates were achieved in the device by micro- surface milling a mold and subsequent PDMS casting. We applied the microfluidic system to measure platelet aggregation in whole porcine blood for shear rates spanning physiological to pathological flow conditions (500-13000 s(-1)). Real-time, non-contact, label-free, microscope-free measurements of platelet aggregation were acquired using an optical system comprising a 650 nm diode laser and a linear CCD. We observed fully occlusive platelet aggregation in less than 20 min above a threshold initial shear rate of 4000 s(-1), and no occlusive platelet aggregation below 1500 s(-1) (N = 86 trials). Accumulation of thrombus was consistent between laser intensity, light microscopy, histology, and mass flow rate measurements. The amount of blood volumes producing occlusion were dependent on shear rate. Times to occlusion were not found to be dependent on shear rate above the threshold level of 4000 s(-1). This microfluidic system enables measurement of the entire process of occlusive platelet thrombosis in whole, unlabeled blood, in vitro, at multiple shear rates. Such a system may be useful as a point-of-care diagnostic tool for studying anti-platelet therapies in individual blood samples from high-risk patients.

New microembolus size estimator for peripheral blood vessels

Several factors affecting the power of Doppler scattered signal and, consequently, microembolus size estimation, may be eliminated when assessing the microembolus size via multiple measurements. A new microembolus size estimator is proposed based on the ratio of microembolus scattering cross-section in two directions and for two emission frequencies. Theoretical considerations indicate that the estimation of size of microembolic elements should be independent of the spatial distribution of the wave intensity, tissue attenuation and hardware factors. The simulation results indicate that this estimation only slightly depends on the material of the microembolus and acoustic properties of blood. The experimental results indicate that the accuracy of median size estimation increases with microembolus size. The measurement error is less than 27% for microemboli with median diameter larger than 360 μm. The method is constrained to the estimation of microembolus size in the vessels of extremities.

Development of a vessel-mimicking material for use in anatomically realistic Doppler flow phantoms

Polyvinyl alcohol cryogel (PVA-C) is presented as a vessel-mimicking material for use in anatomically realistic Doppler flow phantoms. Three different batches of 10% wt PVA-C containing (i) PVA-C alone, (ii) PVA-C with antibacterial agent and (iii) PVA-C with silicon carbide particles were produced, each with 1-6 freeze-thaw cycles. The resulting PVA-C samples were characterized acoustically (over a range 2.65 to 10.5 MHz) and mechanically to determine the optimum mixture and preparation for mimicking the properties of healthy and diseased arteries found in vivo. This optimum mix was reached with the PVA-C with antibacterial agent sample, prepared after two freeze/thaw cycles, which achieved a speed of sound of 1538 ± 5 m s(-1) and a Young's elastic modulus of 79 ± 11 kPa. This material was used to make a range of anatomically realistic flow phantoms with varying degrees of stenoses, and subsequent flow experiments revealed that higher degrees of stenoses and higher velocities could be achieved without phantom rupturing compared with a phantom containing conventional wall-less vessels.

Measurement of the ultrasound attenuation and dispersion in whole human blood and its components from 0-70 MHz

The ultrasound attenuation coefficient and dispersion from 0-70 MHz in whole human blood and its components (red blood cells and plasma) at 37°C is reported. The measurements are made using a fixed path substitution technique that exploits optical mechanisms for the generation and detection of ultrasound. This allows the measurements to cover a broad frequency range with a single source and receiver. The measured attenuation coefficient and dispersion in solutions of red blood cells and physiological saline for total haemoglobin concentrations of 10, 15 and 20 g/dL are presented. The attenuation coefficient and dispersion in whole human blood taken from four healthy volunteers by venipuncture is also reported. The power law dependence of the attenuation coefficient is shown to vary across the measured frequency range. This is due to the varying frequency dependence of the different mechanisms responsible for the attenuation. The attenuation coefficient measured at high frequencies is found to be significantly higher than that predicted by historical power law parameters. A review of the attenuation mechanisms in blood along with previously reported experimental measurements is given. Values for the sound speed and density in the tested samples are also presented.

A tissue phantom for visualization and measurement of ultrasound-induced cavitation damage

Many ultrasound studies involve the use of tissue-mimicking materials to research phenomena in vitro and predict in vivo bioeffects. We have developed a tissue phantom to study cavitation-induced damage to tissue. The phantom consists of red blood cells suspended in an agarose hydrogel. The acoustic and mechanical properties of the gel phantom were found to be similar to soft tissue properties. The phantom's response to cavitation was evaluated using histotripsy. Histotripsy causes breakdown of tissue structures by the generation of controlled cavitation using short, focused, high-intensity ultrasound pulses. Histotripsy lesions were generated in the phantom and kidney tissue using a spherically focused 1-MHz transducer generating 15 cycle pulses, at a pulse repetition frequency of 100 Hz with a peak negative pressure of 14 MPa. Damage appeared clearly as increased optical transparency of the phantom due to rupture of individual red blood cells. The morphology of lesions generated in the phantom was very similar to that generated in kidney tissue at both macroscopic and cellular levels. Additionally, lesions in the phantom could be visualized as hypoechoic regions on a B-mode ultrasound image, similar to histotripsy lesions in tissue. High-speed imaging of the optically transparent phantom was used to show that damage coincides with the presence of cavitation. These results indicate that the phantom can accurately mimic the response of soft tissue to cavitation and provide a useful tool for studying damage induced by acoustic cavitation.

Noninvasive thrombolysis using pulsed ultrasound cavitation therapy - histotripsy

Clinically available thrombolysis techniques are limited by either slow reperfusion (drugs) or invasiveness (catheters) and carry significant risks of bleeding. In this study, the feasibility of using histotripsy as an efficient and noninvasive thrombolysis technique was investigated. Histotripsy fractionates soft tissue through controlled cavitation using focused, short, high-intensity ultrasound pulses. In vitro blood clots formed from fresh canine blood were treated by histotripsy. The treatment was applied using a focused 1-MHz transducer, with five-cycle pulses at a pulse repetition rate of 1kHz. Acoustic pressures varying from 2 to 12MPa peak negative pressure were tested. Our results show that histotripsy can perform effective thrombolysis with ultrasound energy alone. Histotripsy thrombolysis only occurred at peak negative pressure >or=6MPa when initiation of a cavitating bubble cloud was detected using acoustic backscatter monitoring. Blood clots weighing 330mg were completely broken down by histotripsy in 1.5 to 5min. The clot was fractionated to debris with >96% weight smaller than 5mum diameter. Histotripsy thrombolysis treatment remained effective under a fast, pulsating flow (a circulatory model) as well as in static saline. Additionally, we observed that fluid flow generated by a cavitation cloud can attract, trap and further break down clot fragments. This phenomenon may provide a noninvasive method to filter and eliminate hazardous emboli during thrombolysis.

A dual-phantom system for validation of velocity measurements in stenosis models under steady flow

A dual-phantom system is developed for validation of velocity measurements in stenosis models. Pairs of phantoms with identical geometry and flow conditions are manufactured, one for ultrasound and one for particle image velocimetry (PIV). The PIV model is made from silicone rubber, and a new PIV fluid is made that matches the refractive index of 1.41 of silicone. Dynamic scaling was performed to correct for the increased viscosity of the PIV fluid compared with that of the ultrasound blood mimic. The degree of stenosis in the models pairs agreed to less than 1%. The velocities in the laminar flow region up to the peak velocity location agreed to within 15%, and the difference could be explained by errors in ultrasound velocity estimation. At low flow rates and in mild stenoses, good agreement was observed in the distal flow fields, excepting the maximum velocities. At high flow rates, there was considerable difference in velocities in the poststenosis flow field (maximum centreline differences of 30%), which would seem to represent real differences in hydrodynamic behavior between the two models. Sources of error included: variation of viscosity because of temperature (random error, which could account for differences of up to 7%); ultrasound velocity estimation errors (systematic errors); and geometry effects in each model, particularly because of imperfect connectors and corners (systematic errors, potentially affecting the inlet length and flow stability). The current system is best placed to investigate measurement errors in the laminar flow region rather than the poststenosis turbulent flow region.

Surface Instability of Sheared Soft Tissues

When a block made of an elastomer is subjected to a large shear, its surface remains flat. When a block of biological soft tissue is subjected to a large shear, it is likely that its surface in the plane of shear will buckle (appearance of wrinkles). One factor that distinguishes soft tissues from rubberlike solids is the presence—sometimes visible to the naked eye—of oriented collagen fiber bundles, which are stiffer than the elastin matrix into which they are embedded but are nonetheless flexible and extensible. Here we show that the simplest model of isotropic nonlinear elasticity, namely, the incompressible neo-Hookean model, suffers surface instability in shear only at tremendous amounts of shear, i.e., above 3.09, which corresponds to a 72deg angle of shear. Next we incorporate a family of parallel fibers in the model and show that the resulting solid can be either reinforced or strongly weakened with respect to surface instability, depending on the angle between the fibers and the direction of shear and depending on the ratio E∕μ between the stiffness of the fibers and that of the matrix. For this ratio we use values compatible with experimental data on soft tissues. Broadly speaking, we find that the surface becomes rapidly unstable when the shear takes place “against” the fibers and that as E∕μ increases, so does the sector of angles where early instability is expected to occur.

Simulation and validation of arterial ultrasound imaging and blood flow

We reviewed the simulation and validation of arterial ultrasound imaging and blood flow assessment. The physical process of ultrasound imaging and measurement is complex, especially in disease. Simulation of physiological flow in a phantom with tissue equivalence of soft tissue, vessel wall and blood is now achievable. Outstanding issues are concerned with production of anatomical models, simulation of arterial disease, refinement of blood mimics to account for non-Newtonian behavior and validation of velocity measurements against an independent technique such as particle image velocimetry. String and belt phantoms offer simplicity of design, especially for evaluation of velocity estimators, and have a role as portable test objects. Electronic injection and vibrating test objects produce nonphysiologic Doppler signals, and their role is limited. Computational models of the ultrasound imaging and measurement process offer considerable flexibility in their ability to alter multiple parameters of both the propagation medium and ultrasound instrument. For these models, outstanding issues are concerned with the inclusion of different tissue types, multilayer arteries, inhomogeneous tissues and diseased tissues.