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Joyce DP, Morris RI, Black SA, Desai KR, O'Sullivan GJ. Major Complications of Deep Venous Stenting. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03843-5. [PMID: 39214918 DOI: 10.1007/s00270-024-03843-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Deep venous stent placement has developed into a primary treatment modality for venous obstruction in recent decades. Reported rates of complications are low in the literature and are based mainly on case reports and single-centre cohorts. Interventionalists performing these procedures must be aware of the occurrence of complications associated with stent placement to counsel patients adequately and promote avoidance through optimal procedural approach. This study aims to determine the incidence of serious complications associated with iliocaval and iliofemoral stent placement in a cohort of patients from 3 major tertiary deep venous referral centres. METHODS Data were collated from January 2014 to September 2023. The following major complications were included in the analysis: death, major bleeding requiring transfusion, massive pulmonary embolism, any complication which required endovascular or open surgical intervention, vessel rupture, acute kidney injury requiring dialysis, stent crushing, fracture, migration, involution or erosion. RESULTS One thousand eight hundred fourteen (1814) patients were treated for acute or chronic deep venous pathology during the 9-year study period. Sixty-one patients (3.3%) experienced a major stent-related complication. The most frequently reported complication was stent crushing (n = 18, 29.5%), followed by stent fracture (n = 10, 16.4%) and erosion of the stent through the vessel wall (n = 8, 13.1%). Death was a rare event (0.2%). CONCLUSION Deep venous stent placement is a safe procedure with low rates of major complications. It is incumbent upon operators to be aware of the risks associated with these procedures, however, rare, so that they may obtain fully informed consent from patients.
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Affiliation(s)
- D P Joyce
- Department of Interventional Radiology, Galway University Hospital, Galway, Ireland.
| | - R I Morris
- Department of Vascular Surgery, St Thomas' Hospital, London, UK
| | - S A Black
- Department of Vascular Surgery, St Thomas' Hospital, London, UK
| | - K R Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL, USA
| | - G J O'Sullivan
- Department of Interventional Radiology, Galway University Hospital, Galway, Ireland
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2
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Forneris A, Hassanabad AF, Appoo JJ, Di Martino ES. Predicting Aneurysmal Degeneration in Uncomplicated Residual Type B Aortic Dissection. Bioengineering (Basel) 2024; 11:690. [PMID: 39061772 PMCID: PMC11274148 DOI: 10.3390/bioengineering11070690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
The formation of an aneurysm in the false lumen (FL) is a long-term complication in a significant percentage of type B aortic dissection (AD) patients. The ability to predict which patients are likely to progress to aneurysm formation is key to justifying the risks of interventional therapy. The investigation of patient-specific hemodynamics has the potential to enable a patient-tailored approach to improve prognosis by guiding disease management for type B dissection. CFD-derived hemodynamic descriptors and geometric features were used to retrospectively assess individual aortas for a population of residual type B AD patients and analyze correlations with known outcomes (i.e., rapid aortic growth, death). The results highlight great variability in flow patterns and hemodynamic descriptors. A rapid aortic expansion was found to be associated with a larger FL. Time-averaged wall shear stress at the tear region emerged as a possible indicator of the dynamics of flow exchange between lumens and its effect on the evolution of individual aortas. High FL flow rate and tortuosity were associated with adverse outcomes suggesting a role as indicators of risk. AD induces complex changes in vessel geometry and hemodynamics. The reported findings emphasize the need for a patient-tailored approach when evaluating uncomplicated type B AD patients and show the potential of CFD-derived hemodynamics to complement anatomical assessment and help disease management.
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Affiliation(s)
- Arianna Forneris
- Department of Biomedical Engineering, Schulich School of Engineering, University of Calgary, Calgary, AB T2N 1N4, Canada;
- R&D Department, ViTAA Medical Solutions, Montreal, QC H2K 1M6, Canada
| | - Ali F. Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; (A.F.H.); (J.J.A.)
| | - Jehangir J. Appoo
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; (A.F.H.); (J.J.A.)
| | - Elena S. Di Martino
- Department of Biomedical Engineering, Schulich School of Engineering, University of Calgary, Calgary, AB T2N 1N4, Canada;
- R&D Department, ViTAA Medical Solutions, Montreal, QC H2K 1M6, Canada
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Mayer C, Pepe A, Hossain S, Karner B, Arnreiter M, Kleesiek J, Schmid J, Janisch M, Hannes D, Fuchsjäger M, Zimpfer D, Egger J, Mächler H. Type B Aortic Dissection CTA Collection with True and False Lumen Expert Annotations for the Development of AI-based Algorithms. Sci Data 2024; 11:596. [PMID: 38844767 PMCID: PMC11156948 DOI: 10.1038/s41597-024-03284-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 04/22/2024] [Indexed: 06/09/2024] Open
Abstract
Aortic dissections (ADs) are serious conditions of the main artery of the human body, where a tear in the inner layer of the aortic wall leads to the formation of a new blood flow channel, named false lumen. ADs affecting the aorta distally to the left subclavian artery are classified as a Stanford type B aortic dissection (type B AD). This is linked to substantial morbidity and mortality, however, the course of the disease for the individual case is often unpredictable. Computed tomography angiography (CTA) is the gold standard for the diagnosis of type B AD. To advance the tools available for the analysis of CTA scans, we provide a CTA collection of 40 type B AD cases from clinical routine with corresponding expert segmentations of the true and false lumina. Segmented CTA scans might aid clinicians in decision making, especially if it is possible to fully automate the process. Therefore, the data collection is meant to be used to develop, train and test algorithms.
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Affiliation(s)
- Christian Mayer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Antonio Pepe
- Institute of Computer Graphics and Vision (ICG), Graz University of Technology, Inffeldgasse 16/II, 8010, Graz, Austria
| | - Sophie Hossain
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Barbara Karner
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Melanie Arnreiter
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Jens Kleesiek
- Institute for Artificial Intelligence in Medicine (IKIM), AI-guided Therapies (AIT), Essen University Hospital (AöR), Girardetstraße 2, 45131, Essen, Germany
| | - Johannes Schmid
- Division of General Radiology, Department of Radiology, Medical University of Graz, Auenbruggerplatz 9, 8036, Graz, Austria
| | - Michael Janisch
- Division of General Radiology, Department of Radiology, Medical University of Graz, Auenbruggerplatz 9, 8036, Graz, Austria
| | - Deutschmann Hannes
- Division of General Radiology, Department of Radiology, Medical University of Graz, Auenbruggerplatz 9, 8036, Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University of Graz, Auenbruggerplatz 9, 8036, Graz, Austria
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Jan Egger
- Institute of Computer Graphics and Vision (ICG), Graz University of Technology, Inffeldgasse 16/II, 8010, Graz, Austria.
- Institute for Artificial Intelligence in Medicine (IKIM), AI-guided Therapies (AIT), Essen University Hospital (AöR), Girardetstraße 2, 45131, Essen, Germany.
| | - Heinrich Mächler
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria.
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4
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Dagher O, Appoo JJ, Herget E, Atoui R, Baeza C, Brinkman W, Bozinovski J, Chu MWA, Dagenais F, Demers P, Desai N, El-Hamamsy I, Estrera A, Grau JB, Hughes GC, Jassar A, Kachroo P, Lachapelle K, Ouzounian M, Patel HJ, Pozeg Z, Tseng E, Whitlock R, Guo MH, Boodhwani M. Impact of nondiameter aortic indices on surgical eligibility: Results from the Treatment in Thoracic Aortic Aneurysm: Surgery Versus Surveillance (TITAN: SvS) randomized controlled trial. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00308-8. [PMID: 38692478 DOI: 10.1016/j.jtcvs.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Traditional criterion for intervention on an asymptomatic ascending aortic aneurysm has been a maximal aortic diameter of 5.5 cm or more. The 2022 American College of Cardiology/American Heart Association aortic guidelines adopted cross-sectional aortic area/height ratio, aortic size index, and aortic height index as alternate parameters for surgical intervention. The objective of this study was to evaluate the impact of using these newer indices on patient eligibility for surgical intervention in a prospective, multicenter cohort with moderate-sized ascending aortic aneurysms between 5.0 and 5.4 cm. METHODS Patients enrolled from 2018 to 2023 in the randomization or registry arms of the multicenter trial, Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance, were included in the study. Clinical data were captured prospectively in an online database. Imaging data were derived from a core computed laboratory. RESULTS Among the 329 included patients, 20% were female. Mean age was 65.0 ± 11.6 years, and mean maximal aortic diameter was 50.8 ± 3.9 mm. In the one-third of all patients (n = 109) who met any 1 of the 3 criteria (ie, aortic size index ≥3.08 cm/m2, aortic height index ≥3.21 cm/m, or cross-sectional aortic area/height ≥ 10 cm2/m), their mean maximal aortic diameter was 52.5 ± 0.52 mm. Alternate criteria were most commonly met in women compared with men: 20% versus 2% for aortic size index (P < .001), 39% versus 5% for aortic height index (P < .001), and 39% versus 21% for cross-sectional aortic area/height (P = .002), respectively. CONCLUSIONS One-third of patients in Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance would meet criteria for surgical intervention based on novel parameters versus the classic definition of diameter 5.5 cm or more. Surgical thresholds for aortic size index, aortic height index, or cross-sectional aortic area/height ratio are more likely to be met in female patients compared with male patients.
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Affiliation(s)
- Olina Dagher
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, Alberta, Canada; Department of Biomedical Sciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Jehangir J Appoo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, Alberta, Canada.
| | - Eric Herget
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Rony Atoui
- Division of Cardiothoracic Surgery, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Cristian Baeza
- Division of Cardiac Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - William Brinkman
- Division of Cardiothoracic Surgery, Baylor Scott & White Health, Dallas, Tex
| | - John Bozinovski
- Division of Cardiothoracic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Francois Dagenais
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec, Quebec, Canada
| | - Philippe Demers
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Nimesh Desai
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Ismail El-Hamamsy
- Division of Cardiothoracic Surgery, Mount Sinai Hospital, New York, NY
| | - Anthony Estrera
- Department of Cardiothoracic Surgery, McGovern Medical School at UTHealth Houston, Houston, Tex
| | - Juan B Grau
- Division of Cardiothoracic Surgery, The Valley Hospital, Ridgewood, NJ
| | - G Chad Hughes
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Arminder Jassar
- Division of Cardiothoracic Surgery, Massachusetts General Hospital, Boston, Mass
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo
| | - Kevin Lachapelle
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Himanshu J Patel
- Division of Cardiiothoracic Surgery, University of Michigan Hospital, Ann Arbor, Mich
| | - Zlatko Pozeg
- Division of Cardiac Surgery, New Brunswick Heart Centre, Saint John, New-Brunswick, Canada
| | - Elaine Tseng
- Division of Cardiothoracic Surgery, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Richard Whitlock
- Division of Cardiac Surgery, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Yuan X, Kan X, Li J, Yan Y, Mirsadraee S, Mittal T, Shah A, Saunders D, Xu XY, Nienaber CA. Four-dimensional analysis of aortic root motion in normal population using retrospective multiphase computed tomography. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2024; 2:qyae007. [PMID: 39045205 PMCID: PMC11195731 DOI: 10.1093/ehjimp/qyae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/30/2024] [Indexed: 07/25/2024]
Abstract
Aims Aortic root motion is suspected to contribute to proximal aortic dissection. While motion of the aorta in four dimensions can be traced with real-time imaging, displacement and rotation in quantitative terms remain unknown. The hypothesis was to show feasibility of quantification of three-dimensional aortic root motion from dynamic CT imaging. Methods and results Dynamic CT images of 40 patients for coronary assessment were acquired using a dynamic protocol. Scans were ECG-triggered and segmented in 10 time-stepped phases (0-90%) per cardiac cycle. With identification of the sinotubular junction (STJ), a patient-specific co-ordinate system was created with the z-axis (out-of-plane) parallel to longitudinal direction. The left and right coronary ostia were traced at each time-step to quantify downward motion in reference to the STJ plane, motion within the STJ plane (in-plane), and the degree of rotation. Enrolled individuals had an age of 65 ± 12, and 14 were male (35%). The out-of-plane motion was recorded with the largest displacement of 10.26 ± 2.20 and 8.67 ± 1.69 mm referenced by left and right coronary ostia, respectively. The mean downward movement of aortic root was 9.13 ± 1.86 mm. The largest in-plane motion was recorded at 9.17 ± 2.33 mm and 6.51 ± 1.75 mm referenced by left and right coronary ostia, respectively. The largest STJ in-plane motion was 7.37 ± 1.96 mm, and rotation of the aortic root was 11.8 ± 4.60°. Conclusion In vivo spatial and temporal displacement of the aortic root can be identified and quantified from multiphase ECG-gated contrast-enhanced CT images. Knowledge of normal 4D motion of the aortic root may help understand its biomechanical impact in patients with aortopathy and pre- and post-surgical or transcatheter aortic valve replacement.
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Affiliation(s)
- Xun Yuan
- Cardiology and Aortic Centre, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, School of Medicine, Imperial College London, Exhibition Road, London SW7 2BX, UK
| | - Xiaoxin Kan
- Center for Vascular Surgery and Wound Care, Jinshan Hospital, Fudan University, Shanghai, China
- Department of Chemical Engineering, Imperial College London, London, UK
| | - Jianpeng Li
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yang Yan
- Department of Cardiovascular Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Saeed Mirsadraee
- National Heart and Lung Institute, School of Medicine, Imperial College London, Exhibition Road, London SW7 2BX, UK
- Department of Radiology, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Tarun Mittal
- National Heart and Lung Institute, School of Medicine, Imperial College London, Exhibition Road, London SW7 2BX, UK
- Department of Radiology, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Andrew Shah
- Department of Radiology, East and North Hertfordshire NHS Foundation Trust, Middlesex, UK
| | - Debbie Saunders
- Department of Radiology, East and North Hertfordshire NHS Foundation Trust, Middlesex, UK
| | - Xiao Yun Xu
- Department of Chemical Engineering, Imperial College London, London, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, School of Medicine, Imperial College London, Exhibition Road, London SW7 2BX, UK
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6
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Soleimani M, Deo R, Hudobivnik B, Poyanmehr R, Haverich A, Wriggers P. Mathematical modeling and numerical simulation of arterial dissection based on a novel surgeon's view. Biomech Model Mechanobiol 2023; 22:2097-2116. [PMID: 37552344 PMCID: PMC10613153 DOI: 10.1007/s10237-023-01753-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/16/2023] [Indexed: 08/09/2023]
Abstract
This paper presents a mathematical model for arterial dissection based on a novel hypothesis proposed by a surgeon, Axel Haverich, see Haverich (Circulation 135(3):205-207, 2017. https://doi.org/10.1161/circulationaha.116.025407 ). In an attempt and based on clinical observations, he explained how three different arterial diseases, namely atherosclerosis, aneurysm and dissection have the same root in malfunctioning Vasa Vasorums (VVs) which are micro capillaries responsible for artery wall nourishment. The authors already proposed a mathematical framework for the modeling of atherosclerosis which is the thickening of the artery walls due to an inflammatory response to VVs dysfunction. A multiphysics model based on a phase-field approach coupled with mechanical deformation was proposed for this purpose. The kinematics of mechanical deformation was described using finite strain theory. The entire model is three-dimensional and fully based on a macroscopic continuum description. The objective here is to extend that model by incorporating a damage mechanism in order to capture the tearing (rupture) in the artery wall as a result of micro-injuries in VV. Unlike the existing damage-based model of the dissection in the literature, here the damage is driven by the internal bleeding (hematoma) rather than purely mechanical external loading. The numerical implementation is carried out using finite element method (FEM).
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Affiliation(s)
- Meisam Soleimani
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany.
| | - Rohan Deo
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany
| | - Blaz Hudobivnik
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany
| | - Reza Poyanmehr
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medical School, Hannover, Germany
| | - Axel Haverich
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medical School, Hannover, Germany
| | - Peter Wriggers
- Institute of Continuum Mechanics, Leibniz University, Hannover, Germany
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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8
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Brunet J, Pierrat B, Adrien J, Maire E, Lane BA, Curt N, Bravin A, Laroche N, Badel P. In situ visualization of aortic dissection propagation in notched rabbit aorta using synchrotron X-ray tomography. Acta Biomater 2023; 155:449-460. [PMID: 36343907 DOI: 10.1016/j.actbio.2022.10.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
Aortic dissection is a complex, intramural, and dynamic condition involving multiple mechanisms, hence, difficult to observe. In the present study, a controlled in vitro aortic dissection was performed using tension-inflation tests on notched rabbit aortic segments. The mechanical test was combined with conventional (cCT) and synchrotron (sCT) computed tomography for in situ imaging of the macro- and micro-structural morphological changes of the aortic wall during dissection. We demonstrate that the morphology of the notch and the aorta can be quantified in situ at different steps of the aortic dissection, and that the notch geometry correlates with the critical pressure. The phenomena prior to propagation of the notch are also described, for instance the presence of a bulge at the tip of the notch is identified, deforming the remaining wall. Finally, our method allows us to visualize for the first time the propagation of an aortic dissection in real-time with a resolution that has never previously been reached. STATEMENT OF SIGNIFICANCE: With the present study, we investigated the factors leading to the propagation of aortic dissection by reproducing this mechanical process in notched rabbit aortas. Synchrotron CT provided the first visualisation in real-time of an aortic dissection propagation with a resolution that has never previously been reached. The morphology of the intimal tear and aorta was quantified at different steps of the aortic dissection, demonstrating that the early notch geometry correlates with the critical pressure. This quantification is crucial for the development of better criteria identifying patients at risk. Phenomena prior to tear propagation were also described, such as the presence of a bulge at the tip of the notch, deforming the remaining wall.
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Affiliation(s)
- J Brunet
- Mines Saint-Étienne, Univ Jean Monnet, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France; European Synchrotron Radiation Facility (ESRF), Grenoble, France; Department of Mechanical Engineering, University College London, London, UK.
| | - B Pierrat
- Mines Saint-Étienne, Univ Jean Monnet, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France.
| | - J Adrien
- Université de Lyon, INSA-Lyon, MATEIS CNRS UMR5510, Villeurbanne, France
| | - E Maire
- Université de Lyon, INSA-Lyon, MATEIS CNRS UMR5510, Villeurbanne, France
| | - B A Lane
- Mines Saint-Étienne, Univ Jean Monnet, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France
| | - N Curt
- Mines Saint-Étienne, Univ Jean Monnet, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France
| | - A Bravin
- European Synchrotron Radiation Facility (ESRF), Grenoble, France
| | - N Laroche
- Univ Jean Monnet, Mines Saint-Étienne, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France
| | - P Badel
- Mines Saint-Étienne, Univ Jean Monnet, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France
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9
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 486] [Impact Index Per Article: 243.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
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- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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10
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Kefalidi E, Angouras DC, Sokolis DP. Regional and directional variations in the layer-specific resistance to tear propagation in ascending thoracic aortic aneurysms. J Biomech 2022; 138:111133. [DOI: 10.1016/j.jbiomech.2022.111133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
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11
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Abstract
Several studies have investigated the pathogenesis of aortic wall abnormalities such as aortic dissection or aneurysm; however, the comprehensive pathological in situ event involved in the development of the disease is not understood well. The vasa vasorum form a network of capillaries or venules around the adventitia and outer media, which play an important role in the aortic wall structure and function. Impairment of their function may induce tissue hypoxia, impede the transfer of cellular nutrients, and cause aortic medial degeneration, which is considered the major predisposing factor to this aortic wall pathology. This review updates our understanding of the pathological changes in the aortic media and vasa vasorum of patients with aortic dissection and aortic aneurysm.
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Affiliation(s)
- Hiroaki Osada
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto, 606-8507, Japan.
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12
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Uimonen M. Synthesis of multidimensional pathophysiological process leading to type A aortic dissection: a narrative review. J Thorac Dis 2021; 13:6026-6036. [PMID: 34795949 PMCID: PMC8575841 DOI: 10.21037/jtd-21-829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/06/2021] [Indexed: 11/06/2022]
Abstract
Objective This review aims to synthesize the existing knowledge on the etiological process leading to type A aortic dissection (TAAD) and to clarify the relationship between mechanical, biochemical, and histopathological processes behind the aortic disease. Background Extensive research has previously identified several risk factors for TAAD as well as pathological mechanisms leading to TAAD. However, due to the complexity of the pathological process and limited knowledge on the relationships between distinct pathomechanisms leading to TAAD, the ability to identify the patients at high risk for TAAD has been poor. Methods PubMed (National Library of Medicine) database was searched for suitable literature. The most relevant articles focusing on anatomy, histopathology, physiology, and mechanics of ascending aorta and aortic diseases were reviewed. Conclusions Pathophysiology of the TAAD is related to biochemical and histological as well as mechanical and hemodynamic alterations leading to a degeneration of the aortic wall via inflammatory response. The degradative mechanisms of aortic wall structures and the mechanical forces, to which the wall is predisposed, are interrelated and influence one another. The relativity between the factors influencing aortic wall strength and healing capacity, and factors influencing mechanical stress on the aortic wall suggest that the risk of TAAD is not a linear but rather a dynamic phenomenon. Accounting for the dynamical property of the aortic disease in assessing the need for preventive surgical aortic reconstruction may provide a wider perspective in identifying patients at risk of TAAD and in planning preventive medical therapies.
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Affiliation(s)
- Mikko Uimonen
- Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
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13
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Wang Z, Flores N, Lum M, Wisneski AD, Xuan Y, Inman J, Hope MD, Saloner DA, Guccione JM, Ge L, Tseng EE. Wall stress analyses in patients with ≥5 cm versus <5 cm ascending thoracic aortic aneurysm. J Thorac Cardiovasc Surg 2021; 162:1452-1459. [PMID: 32178922 PMCID: PMC8589466 DOI: 10.1016/j.jtcvs.2020.02.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Current guidelines for elective surgery of ascending thoracic aortic aneurysms (aTAAs) use aneurysm size as primary determinant for risk stratification of adverse events. Biomechanically, dissection may occur when wall stress exceeds wall strength. Determining patient-specific aTAA wall stresses by finite element analysis can potentially predict patient-specific risk of dissection. This study compared peak wall stresses in patients with ≥5.0 cm versus <5.0 cm aTAAs to determine correlation between diameter and wall stress. METHODS Patients with aTAA ≥5.0 cm (n = 47) and <5.0 cm (n = 53) were studied. Patient-specific aneurysm geometries obtained from echocardiogram-gated computed tomography were meshed and prestress geometries determined. Peak wall stresses and stress distributions were determined using LS-DYNA finite element analysis software (LSTC Inc, Livermore, Calif), with user-defined fiber-embedded material models under systolic pressure. RESULTS Peak circumferential stresses at systolic pressure were 530 ± 83 kPa for aTAA ≥5.0 cm versus 486 ± 87 kPa for aTAA <5.0 cm (P = .07), whereas peak longitudinal stresses were 331 ± 57 kPa versus 310 ± 54 kPa (P = .08), respectively. For aTAA ≥5.0 cm, correlation between peak circumferential stresses and size was 0.41, whereas correlation between peak longitudinal wall stresses and size was 0.33. However, for aTAA <5.0 cm, correlation between peak circumferential stresses and size was 0.23, whereas correlation between peak longitudinal stresses and size was 0.14. CONCLUSIONS Peak patient-specific aTAA wall stresses overall were larger for ≥5.0 cm than aTAA <5.0 cm. Although some correlation between size and peak wall stresses was found in aTAA ≥5.0 cm, poor correlation existed between size and peak wall stresses in aTAA <5.0 cm. Patient-specific wall stresses are particularly important in determining patient-specific risk of dissection for aTAA <5.0 cm.
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Affiliation(s)
- Zhongjie Wang
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Nick Flores
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Matthew Lum
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Andrew D Wisneski
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Yue Xuan
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Justin Inman
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Michael D Hope
- Department of Radiology, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - David A Saloner
- Department of Radiology, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Julius M Guccione
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Liang Ge
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Elaine E Tseng
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif.
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Tozzi P, Gunga Z, Niclauss L, Delay D, Roumy A, Pfister R, Colombier S, Patella F, Qanadli SD, Kirsch M. Type A aortic dissection in aneurysms having modelled pre-dissection maximum diameter below 45 mm: should we implement current guidelines to improve the survival benefit of prophylactic surgery? Eur J Cardiothorac Surg 2021; 59:473-478. [PMID: 33006606 PMCID: PMC7850065 DOI: 10.1093/ejcts/ezaa351] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. METHODS All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). RESULTS Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort’s mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). CONCLUSIONS TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.
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Affiliation(s)
- Piergiorgio Tozzi
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Ziyad Gunga
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Lars Niclauss
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Dominique Delay
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Aurelian Roumy
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Raymond Pfister
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Sebastien Colombier
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | | | - Salah Dine Qanadli
- Radiology Department, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Matthias Kirsch
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
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Della Corte A, Rubino AS, Montella AP, Bancone C, Lo Presti F, Galbiati D, Dialetto G, De Feo M. Implications of abnormal ascending aorta geometry for risk prediction of acute type A aortic dissection. Eur J Cardiothorac Surg 2021; 60:978-986. [PMID: 34021321 DOI: 10.1093/ejcts/ezab218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/07/2021] [Accepted: 03/09/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Recently, increased length of the ascending aorta has been suggested as a possible risk factor for acute type A aortic dissection (ATAAD). Our goal was to identify measurable aortic geometrical characteristics associated with elongation that could differentiate ATAAD from uncomplicated aortic dilation (>45 mm). METHODS In angiographic computed tomography scans performed in 180 patients having cardiac surgery, aortic diameters, root length, length of the ascending aorta at both the centreline and the greater curvature (convexity) and the root-ascending (root-asc) angle (that between the root axis and the axis of the ascending tract) and the ascending-arch (asc-arch) angle (that between the axis of the ascending aorta and the arch axis) were measured and compared among 3 patient groups: normal aorta (diameter < 45 mm), dilation/aneurysm (>45 mm) and ATAAD. Correlations between diameters and angles, diameters and lengths and lengths and angles were analysed; multivariable analysis including geometrical factors was performed to identify independent predictors of ATAAD. RESULTS Both patients with aneurysms and patients with ATAAD showed significantly elongated ascending aortas (P < 0.001 vs normal). However, in the aneurysms, the root-asc angle (136° ± 20° vs 147° ± 17°; P < 0.001) and in ATAAD the asc-arch angle were uniquely narrower than that in the normal aorta (116° ± 11° vs 132° ± 19°; P < 0.001). All patients with an ATAAD had an asc-arch angle ≤130°. Both in patients with ATAAD and in those without ATAAD, narrowing of the asc-arch angle was associated with elongation of the root segment (P < 0.001). In multivariable analysis, the asc-arch angle and the total length of the ascending aorta (root + tubular) were significant predictors of ATAAD. CONCLUSIONS The asc-arch angle is a promising measurement that could help predict aortic dissection along with aortic diameter and length: further verification is warranted.
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Affiliation(s)
- Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Unit of Cardiac Surgery, V. Monaldi Hospital, Naples, Italy
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Guo Y, Chen X, Lin X, Chen L, Shu J, Pang P, Cheng J, Xu M, Sun Z. Non-contrast CT-based radiomic signature for screening thoracic aortic dissections: a multicenter study. Eur Radiol 2021; 31:7067-7076. [PMID: 33755755 DOI: 10.1007/s00330-021-07768-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/21/2021] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a non-contrast CT-based radiomic signature to effectively screen for thoracic aortic dissections (ADs). METHODS We retrospectively enrolled 378 patients who underwent non-contrast chest CT scans along with CT angiography or MRI from 4 medical centers. The training and validation sets were from 3 centers, while the external test set was from a 4th center. Radiomic features were extracted from non-contrast CT images. The radiomic signature was created on the basis of selected features by a logistic regression algorithm. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve, accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were conducted to assess the predictive ability of radiomic signature. RESULTS The radiomic signature demonstrated AUCs of 0.91 (95% confidence interval [CI], 0.86-0.95) in the training set, 0.92 (95% CI, 0.86-0.98) in the validation set, and 0.90 (95% CI, 0.82-0.98) in the external test set. The predicted diagnosis was in good agreement with the probability of thoracic AD. In the external test group, the diagnostic accuracy, sensitivity, specificity, PPV, and NPV were 90.5%, 85.7%, 91.7%, 70.6%, and 96.5%, respectively. CONCLUSIONS A radiomic signature based on non-contrast CT images can effectively predict thoracic ADs. This method may serve as a potential screening tool for thoracic ADs. KEY POINTS • The non-contrast CT-based radiomic signature can effectively predict the thoracic aortic dissections. • This radiomic signature shows better predictive performance compared to the current clinical model. • This prediction method may be a potential tool for screening thoracic aortic dissections.
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Affiliation(s)
- Yifan Guo
- Department of Radiology, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Hangzhou, 310000, China
- The First Clinical Medical College of Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou, 310000, China
| | - Xiaojun Chen
- Department of Radiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, 365 Renmin East Road, Jinhua, 321000, China
| | - Xianda Lin
- Department of Neurology, The Wenzhou Third Clinical Institute Affiliated To Wenzhou Medical University, 299 Gu'an Road, Wenzhou, 325000, China
| | - Litian Chen
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan West Road, Wenzhou, 325000, China
| | - Jiner Shu
- Department of Radiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, 365 Renmin East Road, Jinhua, 321000, China
| | - Peipei Pang
- Department of Pharmaceuticals Diagnosis, GE Healthcare, 122 Shuguang Road, Hangzhou, 310000, China
| | - Jianmin Cheng
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan West Road, Wenzhou, 325000, China
| | - Maosheng Xu
- Department of Radiology, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Hangzhou, 310000, China.
- The First Clinical Medical College of Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou, 310000, China.
| | - Zhichao Sun
- Department of Radiology, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Hangzhou, 310000, China.
- The First Clinical Medical College of Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou, 310000, China.
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Brunet J, Pierrat B, Badel P. A Parametric Study on Factors Influencing the Onset and Propagation of Aortic Dissection Using the Extended Finite Element Method. IEEE Trans Biomed Eng 2021; 68:2918-2929. [PMID: 33523804 DOI: 10.1109/tbme.2021.3056022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Aortic dissection is a life-threatening event which starts most of the time with an intimal tear propagating along the aortic wall, while blood enters the medial layer and delaminates the medial lamellar units. Studies investigating the mechanisms underlying the initiation sequence of aortic dissection are rare in the literature, the majority of studies being focused on the propagation event. Numerical models can provide a deeper understanding of the phenomena involved during the initiation and the propagation of the initial tear, and how geometrical and mechanical parameters affect this event. In the present paper, we investigated the primary factors contributing to aortic dissection. METHODS A two-layer arterial model with an initial tear was developed, representing three different possible configurations depending on the initial direction of the tear. Anisotropic damage initiation criteria were developed based on uniaxial and shear experiments from the literature to predict the onset and the direction of crack propagation. We used the XFEM-based cohesive segment method to model the initiation and the early propagation of the tear along the aorta. A design of experiment was used to quantify the influence of 7 parameters reflecting crack geometry and mechanics of the wall on the critical pressure triggering the dissection and the directions of propagation of the tear. RESULTS The results showed that the obtained critical pressures (mean range from 206 to 251 mmHg) are in line with measurement from the literature. The medial tensile strength was found to be the most influential factor, suggesting that a medial degeneration is needed to reach a physiological critical pressure and to propagate a tear in an aortic dissection. The geometry of the tear and its location inside the aortic wall were also found to have an important role not only in the triggering of tear propagation, but also in the evolution of the tear into either aortic rupture or aortic dissection. A larger and deeper initial tear increases the risk of aortic dissection. CONCLUSION The numerical model was able to reproduce the behaviour of the aorta during the initiation and propagation of an aortic dissection. In addition to confirm multiple results from the literature, different types of tears were compared and the influence of several geometrical and mechanical parameters on the critical pressure and direction of propagation was evaluated with a parametric study for each tear configuration. SIGNIFICANCE Although these results should be experimentally validated, they allow a better understanding of the phenomena behind aortic dissection and can help in improving the diagnosis and treatment of this disease.
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Ibanez I, de Azevedo Gomes BA, Nieckele AO. Effect of percutaneous aortic valve position on stress map in ascending aorta: A fluid-structure interaction analysis. Artif Organs 2021; 45:O195-O206. [PMID: 33326639 DOI: 10.1111/aor.13883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/06/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is an increasingly widespread procedure. Although this intervention is indicated for high and low surgical risk patients, some issues still remain, such as prosthesis positioning optimization in the aortic annulus. Coaxial positioning of the percutaneous prosthesis influences directly on the aortic wall stress map. The determination of the mechanical stress that acts on the vascular endothelium resulting from blood flow can be considered an important task, since TAVI positioning can lead to unfavorable hemodynamic patterns, resulting in changes in parietal stress, such as those found in post-stenotic dilatation region. This research aims to investigate the influence of the prosthetic valve inclination angle in the mechanical stresses acting in the ascending aortic wall. Aortic compliance and blood flow during cardiac cycle were numerically obtained using fluid structure interaction. The aortic model was developed through segmentation of a computed tomography image of a specific patient submitted to TAVI. When compared to standard position (coaxiality match between the prosthesis and the aortic annulus), the inclination of 4° directed to the left main coronary artery decreased the aortic wall area with high values of wall shear stress and pressure. Coaxial positioning optimization of percutaneous aortic prosthesis may decrease the high mechanical stress area. These changes may be important to reduce the aortic remodeling process, vascular calcification or even the prosthesis half-life. Computational fluid dynamics makes room for personalized medicine, with manufactured prosthesis tailored to each patient.
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Affiliation(s)
- Ivan Ibanez
- Department of Mechanical Engineering, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bruno A de Azevedo Gomes
- Department of Mechanical Engineering, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil.,Instituto Nacional de Cardiologia - MS, Rio de Janeiro, Brazil
| | - Angela O Nieckele
- Department of Mechanical Engineering, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
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Brunet J, Pierrat B, Badel P. Review of Current Advances in the Mechanical Description and Quantification of Aortic Dissection Mechanisms. IEEE Rev Biomed Eng 2021; 14:240-255. [PMID: 31905148 DOI: 10.1109/rbme.2019.2950140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aortic dissection is a life-threatening event associated with a very poor outcome. A number of complex phenomena are involved in the initiation and propagation of the disease. Advances in the comprehension of the mechanisms leading to dissection have been made these last decades, thanks to improvements in imaging and experimental techniques. However, the micro-mechanics involved in triggering such rupture events remains poorly described and understood. It constitutes the primary focus of the present review. Towards the goal of detailing the dissection phenomenon, different experimental and modeling methods were used to investigate aortic dissection, and to understand the underlying phenomena involved. In the last ten years, research has tended to focus on the influence of microstructure on initiation and propagation of the dissection, leading to a number of multiscale models being developed. This review brings together all these materials in an attempt to identify main advances and remaining questions.
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20
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Wang R, Yu X, Gkousioudi A, Zhang Y. Effect of Glycation on Interlamellar Bonding of Arterial Elastin. EXPERIMENTAL MECHANICS 2021; 61:81-94. [PMID: 33583947 PMCID: PMC7880226 DOI: 10.1007/s11340-020-00644-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/21/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Interlamellar bonding in the arterial wall is often compromised by cardiovascular diseases. However, several recent nationwide and hospital-based studies have uniformly reported reduced risk of thoracic aortic dissection in patients with diabetes. As one of the primary structural constituents in the arterial wall, elastin plays an important role in providing its interlamellar structural integrity. OBJECTIVE The purpose of this study is to examine the effects of glycation on the interlamellar bonding properties of arterial elastin. METHODS Purified elastin network was isolated from porcine descending thoracic aorta and incubated in 2 M glucose solution for 7, 14 or 21 days at 37 °C. Peeling and direct tension tests were performed to provide complimentary information on understanding the interlamellar layer separation properties of elastin network with glycation effect. Peeling tests were simulated using a cohesive zone model (CZM). Multiphoton imaging was used to visualize the interlamellar elastin fibers in samples subjected to peeling and direct tension. RESULTS Peeling and direct tension tests show that interlamellar energy release rate and strength both increases with the duration of glucose treatment. The traction at damage initiation estimated for the CZM agrees well with the interlamellar strength measurements from direct tension tests. Glycation was also found to increase the interlamellar failure strain of arterial elastin. Multiphoton imaging confirmed the contribution of radially running elastin fibers to resisting dissection. CONCLUSIONS Nonenzymatic glycation reduces the propensity of arterial elastin to dissection. This study also suggests that the CZM effectively describes the interlamellar bonding properties of arterial elastin.
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Affiliation(s)
- R Wang
- Department of Mechanical Engineering, Boston University, Boston, MA 02215
| | - X Yu
- Department of Mechanical Engineering, Boston University, Boston, MA 02215
| | - A Gkousioudi
- Department of Mechanical Engineering, Boston University, Boston, MA 02215
| | - Y Zhang
- Department of Mechanical Engineering, Boston University, Boston, MA 02215
- Department of Biomedical Engineering, Boston University, Boston, MA 02215
- Divison of Materials Science & Engineering, Boston University, Boston, MA 02215
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21
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Wang R, Yu X, Zhang Y. Mechanical and structural contributions of elastin and collagen fibers to interlamellar bonding in the arterial wall. Biomech Model Mechanobiol 2020; 20:93-106. [PMID: 32705413 DOI: 10.1007/s10237-020-01370-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/15/2020] [Indexed: 12/25/2022]
Abstract
The artery relies on interlamellar structural components, mainly elastin and collagen fibers, for maintaining its integrity and resisting dissection propagation. In this study, the contribution of arterial elastin and collagen fibers to interlamellar bonding was studied through mechanical testing, multiphoton imaging and finite element modeling. Steady-state peeling experiments were performed on porcine aortic media and the purified elastin network in the circumferential (Circ) and longitudinal (Long) directions. The peeling force and energy release rate associated with mode-I failure are much higher for aortic media than for the elastin network. Also, longitudinal peeling exhibits a higher energy release rate and strength than circumferential peeling for both the aortic media and elastin. Multiphoton imaging shows the recruitment of both elastin and collagen fibers within the interlamellar space and points to in-plane anisotropy of fiber distributions as a potential mechanism for the direction-dependent phenomena of peeling tests. Three-dimensional finite element models based on cohesive zone model (CZM) of fracture were created to simulate the peeling tests with the interlamellar energy release rate and separation distance at damage initiation obtained directly from peeling test. Our experimental results show that the separation distance at damage initiation is 80 μm for aortic media and 40 μm for elastin. The damage initiation stress was estimated from the model for aortic media (Circ: 60 kPa; Long: 95 kPa) and elastin (Circ: 9 kPa; Long: 14 kPa). The interlamellar separation distance at complete failure was estimated to be 3 - 4 mm for both media and elastin. Furthermore, elastin and collagen fibers both play an important role in bonding of the arterial wall, while collagen has a higher contribution than elastin to interlamellar stiffness, strength and toughness. These results on microstructural interlamellar failure shed light on the pathological development and progression of aortic dissection.
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Affiliation(s)
- Ruizhi Wang
- Department of Mechanical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA
| | - Xunjie Yu
- Department of Mechanical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA
| | - Yanhang Zhang
- Department of Mechanical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA. .,Department of Biomedical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA. .,Divison of Materials Science & Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA.
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22
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Iliopoulos DC, Sokolis DP. Ascending aorta mechanics in bicuspid aortopathy: controversy or fact? Asian Cardiovasc Thorac Ann 2020; 29:592-604. [PMID: 32447961 DOI: 10.1177/0218492320928731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Bicuspid aortic valve is the most common congenital cardiovascular defect, often associated with proximal aortic dilatation, and the ideal management strategy is debated. The inconsistency in previous and present guideline recommendations emphasizes the insufficiency of the maximal diameter as the sole criterion for prophylactic repair. Our ability to guide clinical decisions may improve through an understanding of the mechanical properties of ascending thoracic aortic aneurysms in bicuspid compared to tricuspid aortic valve patients and non-aneurysmal aortas, because dissection and rupture are aortic wall mechanical failures. Such an understanding of the mechanical properties has been attempted by several authors, and this article addresses whether there is a controversy in the accumulated knowledge. The available mechanical studies are briefly reviewed, discussing factors such as age, sex, and the region of mechanical examination that may be responsible for the lack of unanimity in the reported findings. The rationale for acquiring layer-specific properties is presented along with the main results from our recent study. No mechanical vulnerability of ascending thoracic aortic aneurysms was evidenced in bicuspid aortic valve patients, corroborating present conservative guidelines concerning the management of bicuspid aortopathy. Weakening and additional vulnerability was evidenced in aged patients and those with coexisting valve pathology, aortic root dilatation, hypertension, and hyperlipidemia. Discussion of these results from age- and sex-matched subjects, accounting for the region- and layer-specific aortic heterogeneity, in relation to intact wall results and histologic confirmation, helps to reconcile previous findings and affords a universal interpretation of ascending aorta mechanics in bicuspid aortopathy.
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Affiliation(s)
- Dimitrios C Iliopoulos
- Department of Cardiac Surgery, National and Kapodistrian University of Athens, and 4th Cardiac Surgery Department, Hygeia Hospital, Athens, Greece
| | - Dimitrios P Sokolis
- Biomechanics Laboratory, Center of Clinical, Experimental Surgery, and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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23
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Effect of diabetes mellitus on the dissection properties of the rabbit descending thoracic aortas. J Biomech 2019; 100:109592. [PMID: 31911049 DOI: 10.1016/j.jbiomech.2019.109592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 12/18/2019] [Accepted: 12/18/2019] [Indexed: 01/02/2023]
Abstract
Effect of diabetes mellitus (DM) on the dissection properties of thoracic aortas remains largely unclear and relevant biomechanical analysis is lacking. In the present study forty adult rabbits (1.6-2.2 kg) were collected and type 1 diabetic rabbit model was induced by injection of alloxan. A total of 10 control and 30 diabetic (with different time exposure to diabetic condition) rabbit descending thoracic aortas were harvested. Peeling tests were performed to quantitatively determine force/width values and dissection energy in the control and diabetic aortas. Histological and mass fraction analyses were performed to characterize the dissected morphology and to quantify dry weight percentages of elastin and collagen. The resisting force/width values were significantly higher for the diabetic thoracic aortas (in 8 weeks) than those of the control thoracic aortas (axial: 26.1 ± 4.0 vs. 20.5 ± 3.1 mN/mm, p = 0.04; circ: 19.7 ± 2.8 vs. 15.3 ± 1.9 mN/mm, p = 0.03). There was a higher resistance to the dissection in both axial and circumferential directions for the diabetic aortas. The dissection energy generated by axial and circumferential peeling of the diabetic aortas (in 6 and 8 weeks) was statistically significantly higher than that of the control aortas (axial: 5.6 ± 0.7 vs. 4.3 ± 0.5 mJ/cm2, p = 0.02; circ: 3.9 ± 0.3 vs. 3.2 ± 0.3 mJ/cm2, p = 0.02). Histology showed that dissection mainly occurred in the aortic media and the dissected surfaces were close to external elastic lamina for some specimens. The mass fractions of collagen within the diabetic aortas increased significantly as compared to the control aortas, whereas no significant change was found for that of elastin. Our data suggest that the experimentally induced DM may lead to a lower propensity of dissection for the rabbit thoracic aortas. The dissection properties of the rabbit thoracic aortas vary with time exposed to diabetic condition.
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24
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Korenczuk CE, Dhume RY, Liao KK, Barocas VH. Ex Vivo Mechanical Tests and Multiscale Computational Modeling Highlight the Importance of Intramural Shear Stress in Ascending Thoracic Aortic Aneurysms. J Biomech Eng 2019; 141:121010. [PMID: 31633165 PMCID: PMC7104749 DOI: 10.1115/1.4045270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/17/2019] [Indexed: 11/08/2022]
Abstract
Ascending thoracic aortic aneurysms (ATAAs) are anatomically complex in terms of architecture and geometry, and both complexities contribute to unpredictability of ATAA dissection and rupture in vivo. The goal of this work was to examine the mechanism of ATAA failure using a combination of detailed mechanical tests on human tissue and a multiscale computational model. We used (1) multiple, geometrically diverse, mechanical tests to characterize tissue properties; (2) a multiscale computational model to translate those results into a broadly usable form; and (3) a model-based computer simulation of the response of an ATAA to the stresses generated by the blood pressure. Mechanical tests were performed in uniaxial extension, biaxial extension, shear lap, and peel geometries. ATAA tissue was strongest in circumferential extension and weakest in shear, presumably because of the collagen and elastin in the arterial lamellae. A multiscale, fiber-based model using different fiber properties for collagen, elastin, and interlamellar connections was specified to match all of the experimental data with one parameter set. Finally, this model was used to simulate ATAA inflation using a realistic geometry. The predicted tissue failure occurred in regions of high stress, as expected; initial failure events involved almost entirely interlamellar connections, consistent with arterial dissection-the elastic lamellae remain intact, but the connections between them fail. The failure of the interlamellar connections, paired with the weakness of the tissue under shear loading, is suggestive that shear stress within the tissue may contribute to ATAA dissection.
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Affiliation(s)
- Christopher E. Korenczuk
- Department of Biomedical Engineering, University of Minnesota,7-105 Nils Hasselmo Hall, 312 Church Street SE, Minneapolis, MN 55455e-mail:
| | - Rohit Y. Dhume
- Department of Mechanical Engineering, University of Minnesota,7-105 Nils Hasselmo Hall, 312 Church Street SE, Minneapolis, MN 55455e-mail:
| | - Kenneth K. Liao
- Department of Surgery, University of Minnesota,420 Delaware Street SE, MMC 207, Minneapolis, MN 55455e-mail:
| | - Victor H. Barocas
- Department of Biomedical Engineering, University of Minnesota,7-105 Nils Hasselmo Hall, 312 Church Street SE, Minneapolis, MN 55455e-mail:
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Gültekin O, Hager SP, Dal H, Holzapfel GA. Computational modeling of progressive damage and rupture in fibrous biological tissues: application to aortic dissection. Biomech Model Mechanobiol 2019; 18:1607-1628. [PMID: 31093869 PMCID: PMC6825033 DOI: 10.1007/s10237-019-01164-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
This study analyzes the lethal clinical condition of aortic dissections from a numerical point of view. On the basis of previous contributions by Gültekin et al. (Comput Methods Appl Mech Eng 312:542-566, 2016 and 331:23-52, 2018), we apply a holistic geometrical approach to fracture, namely the crack phase-field, which inherits the intrinsic features of gradient damage and variational fracture mechanics. The continuum framework captures anisotropy, is thermodynamically consistent and is based on finite strains. The balance of linear momentum and the crack evolution equation govern the coupled mechanical and phase-field problem. The solution scheme features the robust one-pass operator-splitting algorithm upon temporal and spatial discretizations. Based on experimental data of diseased human thoracic aortic samples, the elastic material parameters are identified followed by a sensitivity analysis of the anisotropic phase-field model. Finally, we simulate an incipient propagation of an aortic dissection within a multi-layered segment of a thoracic aorta that involves a prescribed initial tear. The finite element results demonstrate a severe damage zone around the initial tear and exhibit a rather helical crack pattern, which aligns with the fiber orientation. It is hoped that the current contribution can provide some directions for further investigations of this disease.
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Affiliation(s)
- Osman Gültekin
- Institute of Biomechanics, Graz University of Technology, Stremayrgasse 16/II, 8010, Graz, Austria.,Department of Mechanical Engineering, Middle East Technical University, Dumlupınar Bulvarı No. 1, Çankaya, 06800, Ankara, Turkey
| | - Sandra Priska Hager
- Institute of Biomechanics, Graz University of Technology, Stremayrgasse 16/II, 8010, Graz, Austria
| | - Hüsnü Dal
- Department of Mechanical Engineering, Middle East Technical University, Dumlupınar Bulvarı No. 1, Çankaya, 06800, Ankara, Turkey
| | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Stremayrgasse 16/II, 8010, Graz, Austria. .,Department of Structural Engineering, Norwegian University of Science and Technology (NTNU), 7491, Trondheim, Norway.
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26
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Cosentino F, Scardulla F, D'Acquisto L, Agnese V, Gentile G, Raffa G, Bellavia D, Pilato M, Pasta S. Computational modeling of bicuspid aortopathy: Towards personalized risk strategies. J Mol Cell Cardiol 2019; 131:122-131. [PMID: 31047985 DOI: 10.1016/j.yjmcc.2019.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/09/2019] [Accepted: 04/26/2019] [Indexed: 11/18/2022]
Abstract
This paper describes current advances on the application of in-silico for the understanding of bicuspid aortopathy and future perspectives of this technology on routine clinical care. This includes the impact that artificial intelligence can provide to develop computer-based clinical decision support system and that wearable sensors can offer to remotely monitor high-risk bicuspid aortic valve (BAV) patients. First, we discussed the benefit of computational modeling by providing tangible examples of in-silico software products based on computational fluid-dynamic (CFD) and finite-element method (FEM) that are currently transforming the way we diagnose and treat cardiovascular diseases. Then, we presented recent findings on computational hemodynamic and structural mechanics of BAV to highlight the potentiality of patient-specific metrics (not-based on aortic size) to support the clinical-decision making process of BAV-associated aneurysms. Examples of BAV-related personalized healthcare solutions are illustrated.
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Affiliation(s)
- Federica Cosentino
- Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", University of Palermo, Piazza delle Cliniche, n.2, 90128 Palermo, Italy; Fondazione Ri.MED, Via Bandiera n.11, 90133 Palermo, Italy
| | - Francesco Scardulla
- Department of Engineering, University of Palermo, Viale delle Scienze Ed.8, 90128 Palermo, Italy
| | - Leonardo D'Acquisto
- Department of Engineering, University of Palermo, Viale delle Scienze Ed.8, 90128 Palermo, Italy
| | - Valentina Agnese
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Via Tricomi n.5, 90127 Palermo, Italy
| | - Giovanni Gentile
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Via Tricomi n.5, 90127 Palermo, Italy
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Via Tricomi n.5, 90127 Palermo, Italy
| | - Diego Bellavia
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Via Tricomi n.5, 90127 Palermo, Italy
| | - Michele Pilato
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Via Tricomi n.5, 90127 Palermo, Italy
| | - Salvatore Pasta
- Fondazione Ri.MED, Via Bandiera n.11, 90133 Palermo, Italy; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Via Tricomi n.5, 90127 Palermo, Italy.
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27
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Berezowski M, Kosiorowska K, Beyersdorf F, Riesterer T, Jasinski M, Plonek T, Siepe M, Czerny M, Rylski B. Modelling of predissection aortic size in acute descending aortic dissection. Interact Cardiovasc Thorac Surg 2019; 29:124-129. [DOI: 10.1093/icvts/ivz028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mikolaj Berezowski
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Kinga Kosiorowska
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Tatjana Riesterer
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Marek Jasinski
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Plonek
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardio-Thoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University of Freiburg, Faculty of Medicine, Heart Center Freiburg University, Freiburg, Germany
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28
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Identification of regional/layer differences in failure properties and thickness as important biomechanical factors responsible for the initiation of aortic dissections. J Biomech 2018; 80:102-110. [DOI: 10.1016/j.jbiomech.2018.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 07/29/2018] [Accepted: 08/22/2018] [Indexed: 11/18/2022]
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29
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Zhu Y, Chen R, Juan YH, Li H, Wang J, Yu Z, Liu H. Clinical validation and assessment of aortic hemodynamics using computational fluid dynamics simulations from computed tomography angiography. Biomed Eng Online 2018; 17:53. [PMID: 29720173 PMCID: PMC5932836 DOI: 10.1186/s12938-018-0485-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 04/23/2018] [Indexed: 02/02/2023] Open
Abstract
Background Hemodynamic information including peak systolic pressure (PSP) and peak systolic velocity (PSV) carry an important role in evaluation and diagnosis of congenital heart disease (CHD). Since MDCTA cannot evaluate hemodynamic information directly, the aim of this study is to provide a noninvasive method based on a computational fluid dynamics (CFD) model, derived from multi-detector computed tomography angiography (MDCTA) raw data, to analyze the aortic hemodynamics in infants with CHD, and validate these results against echocardiography and cardiac catheter measurements. Methods This study included 25 patients (17 males, and 8 females; a median age of 2 years, range: 4 months–4 years) with CHD. All patients underwent both transthoracic echocardiography (TTE) and MDCTA within 2 weeks prior to cardiac catheterization. CFD models were created from MDCTA raw data. Boundary conditions were confirmed by lumped parameter model and transthoracic echocardiography (TTE). Peak systolic velocity derived from CFD models (PSVCFD) was compared to TTE measurements (PSVTTE), while the peak systolic pressure derived from CFD (PSPCFD) was compared to catheterization (PSPCC). Regions with low and high peak systolic wall shear stress (PSWSS) were also evaluated. Results PSVCFD and PSPCFD showed good agreements between PSVTTE (r = 0.968, p < 0.001; mean bias = − 7.68 cm/s) and PSPCC (r = 0.918, p < 0.001; mean bias = 1.405 mmHg). Regions with low and high PSWSS) can also be visualized. Skewing of velocity or helical blood flow was also observed at aortic arch in patients. Conclusions Our result demonstrated that CFD scheme based on MDCTA raw data is an accurate and convenient method in obtaining the velocity and pressure from aorta and displaying the distribution of PSWSS and flow pattern of aorta. The preliminary results from our study demonstrate the capability in combining clinical imaging data and novel CFD tools in infants with CHD and provide a noninvasive approach for diagnose of CHD such as coarctation of aorta in future.
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Affiliation(s)
- Yulei Zhu
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhong Shan Er Lu, Guangzhou, 510080, Guangdong, China.,School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China
| | - Rui Chen
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhong Shan Er Lu, Guangzhou, 510080, Guangdong, China.,School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China
| | - Yu-Hsiang Juan
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Chang Gung University, Taoyuan, Taiwan
| | - He Li
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhong Shan Er Lu, Guangzhou, 510080, Guangdong, China
| | - Jingjing Wang
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhong Shan Er Lu, Guangzhou, 510080, Guangdong, China.,School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China
| | - Zhuliang Yu
- School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China. .,College of Automation Science and Technology, South China University of Technology, 381 Wushan Road, Guangzhou, 510080, Guangdong, China.
| | - Hui Liu
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhong Shan Er Lu, Guangzhou, 510080, Guangdong, China. .,School of Medicine, South China University of Technology, Guangzhou, 510006, Guangdong, China.
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30
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Haslach HW, Siddiqui A, Weerasooriya A, Nguyen R, Roshgadol J, Monforte N, McMahon E. Fracture mechanics of shear crack propagation and dissection in the healthy bovine descending aortic media. Acta Biomater 2018; 68:53-66. [PMID: 29292167 DOI: 10.1016/j.actbio.2017.12.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/06/2017] [Accepted: 12/19/2017] [Indexed: 11/24/2022]
Abstract
This experimental study adopts a fracture mechanics strategy to investigate the mechanical cause of aortic dissection. Inflation of excised healthy bovine aortic rings with a cut longitudinal notch that extends into the media from the intima suggests that an intimal tear may propagate a nearly circumferential-longitudinal rupture surface that is similar to the delamination that occurs in aortic dissection. Radial and 45°-from-radial cut notch orientations, as seen in the thickness surface, produce similar circumferential crack propagation morphologies. Partial cut notches, whose longitudinal length is half the width of the ring, measure the influence of longitudinal material on crack propagation. Such specimens also produce circumferential cracks from the notch root that are visible in the thickness circumferential-radial plane, and often propagate a secondary crack from the base of the notch, visible in the intimal circumferential-longitudinal plane. Inflation of rings with pairs of cut notches demonstrates that a second notch modifies the propagation created in a specimen with a single notch. The circumferential crack propagation is likely a consequence of the laminar medial structure. These fracture surfaces are probably due to non-uniform circumferential shear deformation in the heterogeneous media as the aortic wall expands. The qualitative deformation morphology around the root of the cut notch during inflation is evidence for such shear deformation. The shear apparently results from relative slip in the circumferential direction of collagen fibers. The slip may produce shear in the longitudinal-circumferential plane between medial layers or in the radial-circumferential plane within a medial lamina in an idealized model. Circumferential crack propagation in the media is then a shear mechanical process that might be facilitated by disease of the tissue. STATEMENT OF SIGNIFICANCE An intimal tear of an apparently healthy aortic wall near the aortic arch is life-threatening because it may lead to full rupture or to wall dissection in which delamination of the medial layer extends around most of the aortic circumference. The mechanical events underlying dissection are not definitively established. This experimental fracture mechanics study provides evidence that shear rupture is the main mechanical process underlying aortic dissection. The commonly performed tensile strength tests of aortic tissue are not clinically useful to predict or describe aortic dissection. One implication of the study is that shear tests might produce more fruitful simple assessments of the aortic wall strength. A clinical implication is that when presented with an intimal tear, those who guide care might recommend steps to reduce the shear load on the aorta.
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31
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Mansour AM, Peterss S, Zafar MA, Rizzo JA, Fang H, Charilaou P, Ziganshin BA, Darr UM, Elefteriades JA. Prevention of Aortic Dissection Suggests a Diameter Shift to a Lower Aortic Size Threshold for Intervention. Cardiology 2018; 139:139-146. [DOI: 10.1159/000481930] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/02/2017] [Indexed: 12/14/2022]
Abstract
Background: Multiple studies have quantified the relationship between aortic size and risk of dissection. However, these studies estimated the risk of dissection without accounting for any increase in aortic size from the dissection process itself. Objectives: This study aims to compare aortic size before and after dissection and to evaluate the change in size consequent to the dissection itself. Methods: Fifty-five consecutive patients (29 type A; 26 type B) with aortic dissection and incidental imaging studies prior to dissection were identified and compared to a control group of aneurysm patients (n = 205). The average time between measurement at and prior to dissection was 1.7 ± 1.9 years (1.9 ± 2.0 years mean inter-image time in the control group). A multivariate regression model controlling for growth rate, age, and gender was created to estimate the effect of dissection itself on aortic size. Results: The mean aortic sizes at and prior to dissection were 54.2 ± 7.0 and 45.1 ± 5.7 mm for the ascending aorta, and 47.1 ± 13.8 and 39.5 ± 13.1 mm for the descending aorta, respectively. The multivariable analysis revealed a significant impact of the dissection itself (p < 0.001) and estimated an increase in size of 7.65 mm (ascending aorta) and 6.38 mm (descending aorta). Thus, a proportional estimate of 82.8% (ascending aorta) and 80.8% (descending aorta) of dissections are made at a size lower than the guideline-recommended threshold (55 mm). Conclusions: The aortic diameter increases substantially due to aortic dissection itself and, thus, aortas are being dissected at clinically meaningfully smaller sizes than natural history analyses have previously suggested. These findings have important implications regarding the size at which the risk of dissection is increased.
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32
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Boudoulas KD, Triposkiadis F, Stefanadis C, Boudoulas H. Aortic Size and Aortic Dissection: Does One Size Fit All? Cardiology 2018; 139:147-150. [PMID: 29346797 DOI: 10.1159/000484040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/09/2017] [Indexed: 01/16/2023]
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33
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Numerical modeling of a prototype cardiac assist device by implementing fluid-structure interaction. Artery Res 2018. [DOI: 10.1016/j.artres.2018.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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34
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Chung J, Lachapelle K, Cartier R, Mongrain R, Leask RL. Loss of mechanical directional dependency of the ascending aorta with severe medial degeneration. Cardiovasc Pathol 2017; 26:45-50. [DOI: 10.1016/j.carpath.2016.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/08/2016] [Accepted: 11/09/2016] [Indexed: 01/15/2023] Open
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35
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Evaluating ascending aortic aneurysm tissue toughness: Dependence on collagen and elastin contents. J Mech Behav Biomed Mater 2016; 64:262-71. [DOI: 10.1016/j.jmbbm.2016.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/16/2016] [Accepted: 08/02/2016] [Indexed: 11/23/2022]
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36
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Bukač M, Alber M. Multi-component model of intramural hematoma. J Biomech 2016; 50:42-49. [PMID: 27876369 DOI: 10.1016/j.jbiomech.2016.11.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 01/22/2023]
Abstract
A novel multi-component model is introduced for studying interaction between blood flow and deforming aortic wall with intramural hematoma (IMH). The aortic wall is simulated by a composite structure submodel representing material properties of the three main wall layers. The IMH is described by a poroelasticity submodel which takes into account both the pressure inside hematoma and its deformation. The submodel of the hematoma is fully coupled with the aortic submodel as well as with the submodel of the pulsatile blood flow. Model simulations are used to investigate the relation between the peak wall stress, hematoma thickness and permeability in patients of different age. The results indicate that an increase in hematoma thickness leads to larger wall stress, which is in agreement with clinical data. Further simulations demonstrate that a hematoma with smaller permeability results in larger wall stress, suggesting that blood coagulation in hematoma might increase its mechanical stability. This is in agreement with previous experimental observations of coagulation having a beneficial effect on the condition of a patient with the IMH.
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Affiliation(s)
- Martina Bukač
- Department of Applied and Computational Mathematics and Statistics, University of Notre Dame, Notre Dame, IN 46556, USA.
| | - Mark Alber
- Department of Applied and Computational Mathematics and Statistics, University of Notre Dame, Notre Dame, IN 46556, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Department of Mathematics, University of California, Riverside, CA 92521, USA.
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Giannoglou G, Giannakoulas G, Soulis J, Chatzizisis Y, Perdikides T, Melas N, Parcharidis G, Louridas G. Predicting the Risk of Rupture of Abdominal Aortic Aneurysms by Utilizing Various Geometrical Parameters: Revisiting the Diameter Criterion. Angiology 2016; 57:487-94. [PMID: 17022385 DOI: 10.1177/0003319706290741] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors estimated noninvasively the wall stress distribution for actual abdominal aortic aneurysms (AAAs) in vivo on a patient-to-patient basis and correlated the peak wall stress (PWS) with various geometrical parameters. They studied 39 patients (37 men, mean age 73.7 ± 8.2 years) with an intact AAA (mean diameter 6.3 ± 1.7 cm) undergoing preoperative evaluation with spiral computed tomography (CT). Real 3-dimensional AAA geometry was obtained from image processing. Wall stress was determined by using a finite-element analysis. The aorta was considered isotropic with linear material properties and was loaded with a static pressure of 120.0 mm Hg. Various geometrical parameters were used to characterize the AAAs. PWS and each of the geometrical characteristics were correlated by use of Pearson's rank correlation coefficients. PWS varied from 10.2 to 65.8 N/cm2 (mean value 37.1 ± 9.9 N/cm2). Among the geometrical parameters, the PWS was well correlated with the mean centerline curvature, the maximum centerline curvature, and the maximum centerline torsion of the AAAs. The correlation of PWS with maximum diameter was nonsignificant. Multiple regression analysis revealed that the mean centerline curvature of the AAA was the only significant predictor of PWS and subsequent rupture risk. This noninvasive computational approach showed that geometrical parameters other than the maximum diameter are better indicators of AAA rupture.
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Affiliation(s)
- G Giannoglou
- Cardiovascular Engineering and Atherosclerosis Laboratory, 1st Cardiology Department, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 1 St. Kyriakidi Str, 54637, Thessaloniki, Greece.
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Singh S, Xu X, Pepper J, Izgi C, Treasure T, Mohiaddin R. Effects of aortic root motion on wall stress in the Marfan aorta before and after personalised aortic root support (PEARS) surgery. J Biomech 2016; 49:2076-2084. [DOI: 10.1016/j.jbiomech.2016.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/13/2016] [Accepted: 05/15/2016] [Indexed: 10/21/2022]
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Krüger T, Veseli K, Lausberg H, Vöhringer L, Schneider W, Schlensak C. Regional and directional compliance of the healthy aorta: an ex vivo study in a porcine model. Interact Cardiovasc Thorac Surg 2016; 23:104-11. [PMID: 26993474 DOI: 10.1093/icvts/ivw053] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/25/2016] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To gain differential knowledge about the physiological compliance and wall strength of the different regions of the aorta, including the ascending aorta, arch and descending aorta in both the circumferential and longitudinal directions, and to generate a hypothesis on the pathophysiological mechanisms that lead to Type A aortic dissection. METHODS Fresh tissue specimens from 22 ex vivo porcine aortas were analysed on a tensile tester. Regional and directional compliance, failure stress and failure strain were recorded. RESULTS Aortic compliance appeared as a linear function of the natural logarithm (ln) of wall stress. Compliance significantly decreased along the length of the aorta. In the ascending aorta, longitudinal compliance significantly (P = 0.003) exceeded circumferential compliance, and the outer curvature was more compliant than the inner curvature (P = 0.03). In the descending aorta, this relationship is reversed: the circumferential compliance exceeded the longitudinal compliance, and the outer aspect was more compliant (P = 0.003). The median circumferential failure stress of all aortic segments was in the range of 2000-2750 kPa, whereas the longitudinal failure stress in the ascending aorta and the arch had values of 750-1000 kPa, which were significantly lower (P < 0.05). Surprisingly, the longitudinal failure stress of the inner aspect of the descending aorta was extraordinarily high (2000 kPa). Failure strain, similar to compliance, was highest in the ascending aorta and decreased along the aorta. CONCLUSION The aorta appears to be a complex organ with distinct regional and directional differences in compliance and wall strength that is designed to effectively absorb the kinetic energy of cardiac systole and to cushion the momentum of systolic impact. Under normotensive conditions and a preconditioned physiological morphology, the aortic wall works in the steep part of the logarithmic strain-stress function; under hypertensive conditions and pathological morphology, the wall reacts in an non-compliant manner. The high longitudinal compliance and low failure stress of the ascending aorta and subsequent pathological changes may be the main determinants of the recurrent patho-anatomy of Type A aortic dissection.
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Affiliation(s)
- Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Kujtim Veseli
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Henning Lausberg
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Luise Vöhringer
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Wilke Schneider
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
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Krüger T, Forkavets O, Veseli K, Lausberg H, Vöhringer L, Schneider W, Bamberg F, Schlensak C. Ascending aortic elongation and the risk of dissection. Eur J Cardiothorac Surg 2016; 50:241-7. [PMID: 26984982 DOI: 10.1093/ejcts/ezw025] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 01/12/2016] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Unlike aneurysm formation, the role of ascending aortic elongation in the pathogenesis of Type A aortic dissection (TAD) is largely unclear. We investigated the morphology of healthy, dissected and predissection aortas with a focus on ascending aortic length. METHODS We retrospectively compared clinical and computer tomography angiography (CTA) data from TAD patients (n = 130), patients who developed a TAD in the further clinical course (preTAD, n = 16) and healthy control patients who received a CTA for non-aortic emergencies (n = 165). The length of the ascending aorta was defined as the distance between the sinotubular junction (STJ) and the brachiocephalic trunk (BCT) at the central line, the outer and inner curvature as well as the direct distance in the frontal and sagittal planes. Additionally, the aortic diameters were analysed. RESULTS In the healthy controls, we found a positive correlation of age with the aortic diameter (r = 0.57) and aortic length (r = 0.42). The correlation of the respective parameters with the body size was negligible (r < 0.2). The median ascending aortic diameter at the height of the pulmonary artery in TAD (50 mm) was significantly (P < 0.001) larger compared with the respective diameter of the healthy aortas (34 mm). The diameter of the preTAD aortas (40 mm) was also significantly larger compared with the healthy controls. These proportions were similar in all the aortic diameters. The midline length of the healthy ascending aortas was 71 mm. In the preTAD and TAD aortas, the same values were 81 mm and 92 mm, respectively (both P < 0.001). We evaluated the linear distance between the STJ and the BCT in the frontal plane as an easy-to-measure parameter of aortic length. In the TAD aortas (108 mm) and preTAD aortas (97 mm), this distance was significantly longer compared with the healthy aortas (84 mm). CONCLUSIONS Aortic diameter might not be an optimal parameter to predict dissection. Most aortas dissect at diameters below 55 mm. Both the TAD and preTAD aortas were elongated compared with the healthy controls. Thus, aortic elongation may play a role in the pathogenesis of and may be a risk factor for TAD.
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Affiliation(s)
- Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Oksana Forkavets
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Kujtim Veseli
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Henning Lausberg
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Luise Vöhringer
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Wilke Schneider
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, University Medical Center Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
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Tong J, Cheng Y, Holzapfel GA. Mechanical assessment of arterial dissection in health and disease: Advancements and challenges. J Biomech 2016; 49:2366-73. [PMID: 26948576 DOI: 10.1016/j.jbiomech.2016.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/03/2016] [Indexed: 11/17/2022]
Abstract
Arterial dissection involves a complex series of coupled biomechanical events. The past two decades have witnessed great advances in the understanding of the intrinsic mechanism for dissection initiation, and hence in the development of novel therapeutic strategies for surgical repair. This is due in part to the profound advancements in characterizing emerging behaviors of dissection using state-of-the-art tools in experimental and computational biomechanics. In addition, researchers have identified the important role of the microstructure in determining the tissue׳s fracture modality during dissection propagation. In this review article, we highlight a variety of approaches in terms of biomechanical measurements, computational modeling and histological/microstructural analysis used to characterize a dissection that propagates in healthy and diseased arteries. Notable findings with quantitative mechanical data are reviewed. We conclude by discussing some unsolved problems that are of interest for future research.
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Affiliation(s)
- Jianhua Tong
- Shanghai East Hospital, Institute for Biomedical Engineering & Nano Science, Tongji University School of Medicine, Shanghai, PR China
| | - Yu Cheng
- Shanghai East Hospital, Institute for Biomedical Engineering & Nano Science, Tongji University School of Medicine, Shanghai, PR China
| | - Gerhard A Holzapfel
- Graz University of Technology, Institute of Biomechanics, Stremayrgasse 16-II, 8010 Graz, Austria.
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Krishnan K, Ge L, Haraldsson H, Hope MD, Saloner DA, Guccione JM, Tseng EE. Ascending thoracic aortic aneurysm wall stress analysis using patient-specific finite element modeling of in vivo magnetic resonance imaging. Interact Cardiovasc Thorac Surg 2015; 21:471-80. [PMID: 26180089 DOI: 10.1093/icvts/ivv186] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 04/17/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Rupture/dissection of ascending thoracic aortic aneurysms (aTAAs) carries high mortality and occurs in many patients who did not meet size criteria for elective surgery. Elevated wall stress may better predict adverse events, but cannot be directly measured in vivo, rather determined from finite element (FE) simulations. Current computational models make assumptions that limit accuracy, most commonly using in vivo imaging geometry to represent zero-pressure state. Accurate patient-specific wall stress requires models with zero-pressure three-dimensional geometry, material properties, wall thickness and residual stress. We hypothesized that wall stress calculated from in vivo imaging geometry at systemic pressure underestimates that using zero-pressure geometry. We developed a novel method to derive zero-pressure geometry from in vivo imaging at systemic pressure. The purpose of this study was to develop the first patient-specific aTAA models using magnetic resonance imaging (MRI) to assess material properties and zero-pressure geometry. Wall stress results from FE models using systemic pressure were compared with those from models using zero-pressure correction. METHODS Patients with aTAAs <5 cm underwent ECG-gated computed tomography angiography (CTA) and displacement encoding with stimulated echo (DENSE)-MRI. CTA lumen geometry was used to create surface contour meshes of aTAA geometry. DENSE-MRI measured cyclic aortic wall strain from which wall material property was derived. Zero- and systemic pressure geometries were created. Simulations were loaded to systemic pressure using the ABAQUS FE software. Wall stress analyses were compared between zero-pressure-corrected and systemic pressure geometry FE models. RESULTS Peak first principal wall stress (primarily aligned in the circumferential direction) at systolic pressure for the zero-pressure correction models was 430.62 ± 69.69 kPa, whereas that without zero-pressure correction was 312.55 ± 39.65 kPa (P = 0.004). Peak second principal wall stress (primarily aligned in the longitudinal direction) at systolic pressure for the zero-pressure correction models was 200.77 ± 43.13 kPa, whereas that without zero-stress correction was 156.25 ± 25.55 kPa (P = 0.02). CONCLUSIONS Previous FE aTAA models from in vivo CT and MRI have not accounted for zero-pressure geometry or patient-specific material property. We demonstrated that zero-pressure correction significantly impacts wall stress results. Future computational models that use wall stress to predict aTAA adverse events must take into account zero-pressure geometry and patient material property for accurate wall stress determination.
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Affiliation(s)
- Kapil Krishnan
- Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Liang Ge
- Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Henrik Haraldsson
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Michael D Hope
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - David A Saloner
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Julius M Guccione
- Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Elaine E Tseng
- Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
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Computational Biomechanics in Thoracic Aortic Dissection: Today’s Approaches and Tomorrow’s Opportunities. Ann Biomed Eng 2015; 44:71-83. [DOI: 10.1007/s10439-015-1366-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/11/2015] [Indexed: 01/16/2023]
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Izgi C, Nyktari E, Alpendurada F, Bruengger AS, Pepper J, Treasure T, Mohiaddin R. Effect of personalized external aortic root support on aortic root motion and distension in Marfan syndrome patients. Int J Cardiol 2015; 197:154-60. [PMID: 26134372 DOI: 10.1016/j.ijcard.2015.06.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 05/27/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Personalized external aortic root support (PEARS) is a novel surgical approach with the aim of stabilizing the aortic root size and decreasing risk of dissection in Marfan syndrome patients. A bespoke polymer mesh tailored to each patient's individual aorta shape is produced by modeling and then surgically implanted. The aim of this study is to assess the mechanical effects of PEARS on the aortic root systolic downward motion (an important determinant of aortic wall stress), aortic root distension and on the left ventricle (LV). METHODS/RESULTS A cohort of 27 Marfan patients had a prophylactic PEARS surgery between 2004 and 2012 with 24 having preoperative and follow-up cardiovascular magnetic resonance imaging studies. Systolic downward aortic root motion, aortic root distension, LV volumes/mass and mitral annular systolic excursion before the operation and in the latest follow-up were measured randomly and blinded. After a median follow-up of 50.5 (IQR 25.5-72) months following implantation of PEARS, systolic downward motion of aortic root was significantly decreased (12.6±3.6mm pre-operation vs 7.9±2.9mm latest follow-up, p<0.00001). There was a tendency for a decrease in systolic aortic root distension but this was not significant (median 4.5% vs 2%, p=0.35). There was no significant change in LV volumes, ejection fraction, mass and mitral annular systolic excursion in follow-up. CONCLUSIONS PEARS surgery decreases systolic downward aortic root motion which is an important determinant of longitudinal aortic wall stress. Aortic wall distension and Windkessel function are not significantly impaired in the follow-up after implantation of the mesh which is also supported by the lack of deterioration of LV volumes or mass.
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Affiliation(s)
- Cemil Izgi
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Evangelia Nyktari
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | | | | | - John Pepper
- Department of Cardiac Surgery, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - Raad Mohiaddin
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK; NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
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Alimohammadi M, Sherwood JM, Karimpour M, Agu O, Balabani S, Díaz-Zuccarini V. Aortic dissection simulation models for clinical support: fluid-structure interaction vs. rigid wall models. Biomed Eng Online 2015; 14:34. [PMID: 25881252 PMCID: PMC4407424 DOI: 10.1186/s12938-015-0032-6] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/02/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The management and prognosis of aortic dissection (AD) is often challenging and the use of personalised computational models is being explored as a tool to improve clinical outcome. Including vessel wall motion in such simulations can provide more realistic and potentially accurate results, but requires significant additional computational resources, as well as expertise. With clinical translation as the final aim, trade-offs between complexity, speed and accuracy are inevitable. The present study explores whether modelling wall motion is worth the additional expense in the case of AD, by carrying out fluid-structure interaction (FSI) simulations based on a sample patient case. METHODS Patient-specific anatomical details were extracted from computed tomography images to provide the fluid domain, from which the vessel wall was extrapolated. Two-way fluid-structure interaction simulations were performed, with coupled Windkessel boundary conditions and hyperelastic wall properties. The blood was modelled using the Carreau-Yasuda viscosity model and turbulence was accounted for via a shear stress transport model. A simulation without wall motion (rigid wall) was carried out for comparison purposes. RESULTS The displacement of the vessel wall was comparable to reports from imaging studies in terms of intimal flap motion and contraction of the true lumen. Analysis of the haemodynamics around the proximal and distal false lumen in the FSI model showed complex flow structures caused by the expansion and contraction of the vessel wall. These flow patterns led to significantly different predictions of wall shear stress, particularly its oscillatory component, which were not captured by the rigid wall model. CONCLUSIONS Through comparison with imaging data, the results of the present study indicate that the fluid-structure interaction methodology employed herein is appropriate for simulations of aortic dissection. Regions of high wall shear stress were not significantly altered by the wall motion, however, certain collocated regions of low and oscillatory wall shear stress which may be critical for disease progression were only identified in the FSI simulation. We conclude that, if patient-tailored simulations of aortic dissection are to be used as an interventional planning tool, then the additional complexity, expertise and computational expense required to model wall motion is indeed justified.
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Affiliation(s)
- Mona Alimohammadi
- Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK.
| | - Joseph M Sherwood
- Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK. .,Bioengineering, Imperial College London, South Kensington Campus, London, SW7 2BP, UK.
| | - Morad Karimpour
- Mechanical Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK.
| | - Obiekezie Agu
- Vascular Unit, University College Hospital, 235 Euston Road, London, NW1 2BU, UK.
| | - Stavroula Balabani
- Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK.
| | - Vanessa Díaz-Zuccarini
- Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK.
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Martin C, Sun W, Elefteriades J. Patient-specific finite element analysis of ascending aorta aneurysms. Am J Physiol Heart Circ Physiol 2015; 308:H1306-16. [PMID: 25770248 DOI: 10.1152/ajpheart.00908.2014] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/03/2015] [Indexed: 12/30/2022]
Abstract
Catastrophic ascending aorta aneurysm (AsAA) dissection and rupture can be prevented by elective surgical repair, but identifying individuals at risk remains a challenge. Typically the decision to operate is based primarily on the overall aneurysm size, which may not be a reliable indicator of risk. In this study, AsAA inflation and rupture was simulated in 27 patient-specific finite element models constructed from clinical CT imaging data and tissue mechanical testing data from matching patients. These patients included n = 8 with concomitant bicuspid aortic valve (BAV), n = 10 with bovine aortic arch (BAA), and n = 10 with neither BAV nor BAA. AsAA rupture risk was found to increase with elevated systolic wall stress and tissue stiffness. The aortic size index was sufficient for identifying the patients with the lowest risk of rupture, but unsuitable for delineating between patients at moderate and high risk. There was no correlation between BAV or BAA and AsAA rupture risk; however, the AsAA morphology was different among these patients. These results support the use of mechanical parameters such as vessel wall stress and tissue stiffness for AsAA presurgical evaluation.
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Affiliation(s)
- Caitlin Martin
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia; and
| | - Wei Sun
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia; and
| | - John Elefteriades
- Aortic Institute of Yale-New Haven Hospital, Yale University, New Haven, Connecticut
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Elastic properties of the young aorta:ex vivoperfusion experiments in a porcine model. Eur J Cardiothorac Surg 2014; 48:221-7. [DOI: 10.1093/ejcts/ezu438] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 10/17/2014] [Indexed: 11/14/2022] Open
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Lee JJ, D'Ancona G, Amaducci A, Follis F, Pilato M, Pasta S. Role of Computational Modeling in Thoracic Aortic Pathology:
A Review. J Card Surg 2014; 29:653-62. [DOI: 10.1111/jocs.12413] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jake J. Lee
- School of Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Giuseppe D'Ancona
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Andrea Amaducci
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Fabrizio Follis
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Michele Pilato
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
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Yang AS, Wen CY, Tseng LY, Chiang CC, Tseng WYI, Yu HY. An innovative numerical approach to resolve the pulse wave velocity in a healthy thoracic aorta model. Comput Methods Biomech Biomed Engin 2014; 17:461-73. [PMID: 22657104 DOI: 10.1080/10255842.2012.691476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Aortic dissection and atherosclerosis are highly fatal diseases. The development of both diseases is closely associated with highly complex haemodynamics. Thus, in predicting the onset of cardiac disease, it is desirable to obtain a detailed understanding of the flowfield characteristics in the human cardiovascular circulatory system. Accordingly, in this study, a numerical model of a normal human thoracic aorta is constructed using the geometry information obtained from a phase-contrast magnetic resonance imaging (PC-MRI) technique. The interaction between the blood flow and the vessel wall dynamics is then investigated using a coupled fluid-structure interaction (FSI) analysis. The simulations focus specifically on the flowfield characteristics and pulse wave velocity (PWV) of the blood flow. Instead of using a conventional PC-MRI method to measure PWV, we present an innovative application of using the FSI approach to numerically resolve PWV for the assessment of wall compliance in a thoracic aorta model. The estimated PWV for a normal thoracic aorta agrees well with the results obtained via PC-MRI measurement. In addition, simulations which consider the FSI effect yield a lower predicted value of the wall shear stress at certain locations in the cardiac cycle than models which assume a rigid vessel wall. Consequently, the model provides a suitable basis for the future development of more sophisticated methods capable of performing the computer-aided analysis of aortic blood flows.
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Affiliation(s)
- An-Shik Yang
- a Department of Energy and Refrigerating Air-Conditioning Engineering , National Taipei University of Technology , 1, Section 3, Chung-Hsiao E. Road, Taipei 106 , Taiwan R.O.C
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Qiao A, Yin W, Chu B. Numerical simulation of fluid–structure interaction in bypassed DeBakey III aortic dissection. Comput Methods Biomech Biomed Engin 2014; 18:1173-1180. [DOI: 10.1080/10255842.2014.881806] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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