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Murasato Y, Meno K, Mori T, Tanenaka K. Impact of coronary bifurcation angle on the pathogenesis of atherosclerosis and clinical outcome of coronary bifurcation intervention–A scoping review. PLoS One 2022; 17:e0273157. [PMID: 35976920 PMCID: PMC9385039 DOI: 10.1371/journal.pone.0273157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background A coronary bifurcation stenting is still a challenging issue due to frequent restenosis and stent thrombosis even with drug-eluting stents. The bifurcation angle (BA) between a main vessel and a side branch is one of the crucial determinants of coronary flow and shear stress that affect the plaque distribution. Previous bench and clinical studies have evaluated the impact of the BA between the proximal main vessel and the side branch (Angle A) and the BA between the distal main vessel and the side branch (Angle B) on the clinical outcomes of bifurcation stenting. However, the impact has not yet been fully elucidated due to a lack of statistical power or different manner of the assessment of BA. Objectives To analyze the published studies on coronary artery BA, the modalities used for assessment, and the impact of BA on interventions and attempt to define the pre-procedural protocols. Data sources A scoping review was performed using the Joanna Briggs Institute Methodology. A total of 52 relevant references were selected from PubMed, Cochrane Library, and CINAHL databases and categorized into three topic areas. Results and conclusions A wider Angle A is associated with the increased likelihood of carina shift and a wider Angle B, with that of side branch occlusion. A wider Angle B promotes stent malapposition and deformation in the side branch ostium and has been reported as an independent predictor of major adverse cardiac events after bifurcation stenting; however, improvement of the drug-eluting stent, refinement of the stenting technique, and accurate 3-dimensional assessment may attenuate the adverse clinical impact of a wider BA. Implications of key findings Assessment of the BA is necessary to predict the effect of bifurcation intervention procedure on the stent configuration and coronary flow at the bifurcated vessels. This will help to optimize stent selection and the stenting technique.
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Affiliation(s)
- Yoshinobu Murasato
- Department of Cardiology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
- * E-mail:
| | - Kyohei Meno
- Department of Cardiology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Takahiro Mori
- Department of Cardiology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Katsuhiko Tanenaka
- Department of Cardiology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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Rampat R, Mayo T, Hildick-Smith D, Cockburn J. A randomized trial comparing two stent sizing strategies in coronary bifurcation treatment with bioresorbable vascular scaffolds - The Absorb Bifurcation Coronary (ABC) trial. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:43-49. [PMID: 30170828 DOI: 10.1016/j.carrev.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/23/2018] [Accepted: 08/10/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Limited information is available on the use of Bioresorbable Vascular Scaffold (BVS) in bifurcations involving significant side branches. When treating bifurcation disease with metal stents, the recommendation is to choose a stent diameter based on the distal main vessel diameter. Whether this sizing strategy is applicable to BVS is currently unknown. METHODS We randomised 37 patients undergoing elective PCI for 'false' bifurcation disease (Medina 0,1,0; 1,0,0; 1,1,0) to receive BVS based either on proximal or distal reference diameters. Optical Frequency Domain Imaging (OFDI) measurements were performed pre BVS insertion to obtain proximal and distal reference diameters and post implantation. BVS size was chosen according to the proximal or distal reference diameter as per randomisation. Implantation was performed using the PSP technique tailored to bifurcation stenting. OFDI was repeated post implantation to confirm satisfactory expansion and apposition. RESULTS Baseline demographics between the two groups were similar. Patients were aged 62.8 ± 3.3 years; 76% were male. Mean side branch diameter was 2.24 ± 0.13 mm. TIMI III flow in the main vessel was achieved in all cases. Side branch occlusion occurred in 1 case (2.7%). In the distal-sizing arm, there was a greater incidence of significant malapposition (>300 μm) at the proximal end of the scaffold on OCT (2.3% versus 0.8%, p 0.023). The incidence of distal edge dissections was numerically greater in the proximal-sizing group but this was not statistically significant (31.3% vs 11.8%, p 0.17). CONCLUSION Both proximal and distal sizing strategies have similar procedural complication rates when using the ABSORB BVS to treat coronary bifurcations. However a proximal sizing strategy is associated with less malapposition and may be preferable.
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Affiliation(s)
- Rajiv Rampat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, BN2 5BE, UK; Brighton and Sussex Medical School, BN1 9PX, UK.
| | - Thomas Mayo
- Brighton and Sussex Medical School, BN1 9PX, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, BN2 5BE, UK
| | - James Cockburn
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, BN2 5BE, UK
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Ormiston JA, Kassab G, Finet G, Chatzizisis YS, Foin N, Mickley TJ, Chiastra C, Murasato Y, Hikichi Y, Wentzel JJ, Darremont O, Iwasaki K, Lefèvre T, Louvard Y, Beier S, Hojeibane H, Netravali A, Wooton J, Cowan B, Webster MW, Medrano-Gracia P, Stankovic G. Bench testing and coronary artery bifurcations: a consensus document from the European Bifurcation Club. EUROINTERVENTION 2018; 13:e1794-e1803. [PMID: 29131803 DOI: 10.4244/eij-d-17-00270] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This is a consensus document from the European Bifurcation Club concerning bench testing in coronary artery bifurcations. It is intended to provide guidelines for bench assessment of stents and other strategies in coronary bifurcation treatment where the United States Food and Drug Administration (FDA) or International Organization for Standardization (ISO) guidelines are limited or absent. These recommendations provide guidelines rather than a step-by-step manual. We provide data on the anatomy of bifurcations and elastic response of coronary arteries to aid model construction. We discuss testing apparatus, bench testing endpoints and bifurcation nomenclature.
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Iannaccone F, Chiastra C, Karanasos A, Migliavacca F, Gijsen F, Segers P, Mortier P, Verhegghe B, Dubini G, De Beule M, Regar E, Wentzel J. Impact of plaque type and side branch geometry on side branch compromise after provisional stent implantation: a simulation study. EUROINTERVENTION 2017; 13:e236-e245. [DOI: 10.4244/eij-d-16-00498] [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] [Indexed: 11/23/2022]
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Chiastra C, Gallo D, Tasso P, Iannaccone F, Migliavacca F, Wentzel JJ, Morbiducci U. Healthy and diseased coronary bifurcation geometries influence near-wall and intravascular flow: A computational exploration of the hemodynamic risk. J Biomech 2017; 58:79-88. [PMID: 28457603 DOI: 10.1016/j.jbiomech.2017.04.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/08/2017] [Accepted: 04/11/2017] [Indexed: 01/09/2023]
Abstract
Local hemodynamics has been identified as one main determinant in the onset and progression of atherosclerotic lesions at coronary bifurcations. Starting from the observation that atherosensitive hemodynamic conditions in arterial bifurcation are majorly determined by the underlying anatomy, the aim of the present study is to investigate how peculiar coronary bifurcation anatomical features influence near-wall and intravascular flow patterns. Different bifurcation angles and cardiac curvatures were varied in population-based, idealized models of both stenosed and unstenosed bifurcations, representing the left anterior descending (LAD) coronary artery with its diagonal branch. Local hemodynamics was analyzed in terms of helical flow and exposure to low/oscillatory shear stress by performing computational fluid dynamics simulations. Results show that bifurcation angle impacts lowly hemodynamics in both stenosed and unstenosed cases. Instead, curvature radius influences the generation and transport of helical flow structures, with smaller cardiac curvature radius associated to higher helicity intensity. Stenosed bifurcation models exhibit helicity intensity values one order of magnitude higher than the corresponding unstenosed cases. Cardiac curvature radius moderately affects near-wall hemodynamics of the stenosed cases, with smaller curvature radius leading to higher exposure to low shear stress and lower exposure to oscillatory shear stress. In conclusion, the proposed controlled benchmark allows investigating the effect of various geometrical features on local hemodynamics at the LAD/diagonal bifurcation, highlighting that cardiac curvature influences near wall and intravascular hemodynamics, while bifurcation angle has a minor effect.
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Affiliation(s)
- Claudio Chiastra
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands; Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Diego Gallo
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Paola Tasso
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | | | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands
| | - Umberto Morbiducci
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy.
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Medrano-Gracia P, Ormiston J, Webster M, Beier S, Young A, Ellis C, Wang C, Smedby Ö, Cowan B. A computational atlas of normal coronary artery anatomy. EUROINTERVENTION 2016; 12:845-54. [DOI: 10.4244/eijv12i7a139] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Chiastra C, Iannaccone F, Grundeken MJ, Gijsen FJH, Segers P, De Beule M, Serruys PW, Wykrzykowska JJ, van der Steen AFW, Wentzel JJ. Coronary fractional flow reserve measurements of a stenosed side branch: a computational study investigating the influence of the bifurcation angle. Biomed Eng Online 2016; 15:91. [PMID: 27495804 PMCID: PMC4974683 DOI: 10.1186/s12938-016-0211-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/20/2016] [Indexed: 12/31/2022] Open
Abstract
Background Coronary hemodynamics and physiology specific for bifurcation lesions was not well understood. To investigate the influence of the bifurcation angle on the intracoronary hemodynamics of side branch (SB) lesions computational fluid dynamics simulations were performed. Methods A parametric model representing a left anterior descending—first diagonal coronary bifurcation lesion was created according to the literature. Diameters obeyed fractal branching laws. Proximal and distal main branch (DMB) stenoses were both set at 60 %. We varied the distal bifurcation angles (40°, 55°, and 70°), the flow splits to the DMB and SB (55 %:45 %, 65 %:35 %, and 75 %:25 %), and the SB stenoses (40, 60, and 80 %), resulting in 27 simulations. Fractional flow reserve, defined as the ratio between the mean distal stenosis and mean aortic pressure during maximal hyperemia, was calculated for the DMB and SB (FFRSB) for all simulations. Results The largest differences in FFRSB comparing the largest and smallest bifurcation angles were 0.02 (in cases with 40 % SB stenosis, irrespective of the assumed flow split) and 0.05 (in cases with 60 % SB stenosis, flow split 55 %:45 %). When the SB stenosis was 80 %, the difference in FFRSB between the largest and smallest bifurcation angle was 0.33 (flow split 55 %:45 %). By describing the ΔPSB−QSB relationship using a quadratic curve for cases with 80 % SB stenosis, we found that the curve was steeper (i.e. higher flow resistance) when bifurcation angle increases (ΔP = 0.451*Q + 0.010*Q2 and ΔP = 0.687*Q + 0.017*Q2 for 40° and 70° bifurcation angle, respectively). Our analyses revealed complex hemodynamics in all cases with evident counter-rotating helical flow structures. Larger bifurcation angles resulted in more pronounced helical flow structures (i.e. higher helicity intensity), when 60 or 80 % SB stenoses were present. A good correlation (R2 = 0.80) between the SB pressure drop and helicity intensity was also found. Conclusions Our analyses showed that, in bifurcation lesions with 60 % MB stenosis and 80 % SB stenosis, SB pressure drop is higher for larger bifurcation angles suggesting higher flow resistance (i.e. curves describing the ΔPSB−QSB relationship being steeper). When the SB stenosis is mild (40 %) or moderate (60 %), SB resistance is minimally influenced by the bifurcation angle, with differences not being clinically meaningful. Our findings also highlighted the complex interplay between anatomy, pressure drops, and blood flow helicity in bifurcations.
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Affiliation(s)
- Claudio Chiastra
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands.,Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Francesco Iannaccone
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands.,IbiTech-bioMMeda, Department of Electronics and Information Systems iMinds Medical IT, Ghent University, Ghent, Belgium
| | - Maik J Grundeken
- The Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Frank J H Gijsen
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands
| | - Patrick Segers
- IbiTech-bioMMeda, Department of Electronics and Information Systems iMinds Medical IT, Ghent University, Ghent, Belgium
| | - Matthieu De Beule
- IbiTech-bioMMeda, Department of Electronics and Information Systems iMinds Medical IT, Ghent University, Ghent, Belgium.,FEops bvba, Ghent, Belgium
| | - Patrick W Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK
| | - Joanna J Wykrzykowska
- The Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands.
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Stenting of the proximal left anterior descending and restenosis: in the shadow of the left main bifurcation. Coron Artery Dis 2016; 27:439-41. [PMID: 27465640 DOI: 10.1097/mca.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Grundeken MJ, Magro M, Gil R, Briguori C, Sardella G, Berland J, Wykrzykowska JJ, Serruys PW. Dedicated stents for distal left main stenting. EUROINTERVENTION 2016; 11 Suppl V:V129-34. [PMID: 25983146 DOI: 10.4244/eijv11sva29] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Left main (LM) coronary bifurcation lesions have different anatomic features from non-LM bifurcation lesions. Dedicated bifurcation devices might facilitate percutaneous coronary intervention (PCI) of LM bifurcations and improve procedural and clinical outcomes. In this review we will discuss the available clinical data on dedicated bifurcation devices for the treatment of LM bifurcation lesions. Furthermore, we will try to discuss all the theoretical advantages and potential drawbacks of these devices in terms of their use in the LM.
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Affiliation(s)
- Maik J Grundeken
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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ZHANG DONG, DOU KEFEI. Coronary Bifurcation Intervention: What Role Do Bifurcation Angles Play? J Interv Cardiol 2015; 28:236-48. [DOI: 10.1111/joic.12203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- DONG ZHANG
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute; Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing 100037 China
| | - KEFEI DOU
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute; Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing 100037 China
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Frattolin J, Zarandi MM, Pagiatakis C, Bertrand OF, Mongrain R. Numerical study of stenotic side branch hemodynamics in true bifurcation lesions. Comput Biol Med 2015; 57:130-8. [DOI: 10.1016/j.compbiomed.2014.11.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 11/19/2014] [Accepted: 11/28/2014] [Indexed: 11/15/2022]
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Burzotta F, Mortier P, Trani C. Characteristics of drug-eluting stent platforms potentially influencing bifurcated lesion provisional stenting procedure. EUROINTERVENTION 2015; 10:124-32. [PMID: 24832640 DOI: 10.4244/eijv10i1a19] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS We aimed to review the technical characteristics of DES platforms which have been documented to influence bifurcation stenting procedures conducted according to the provisional approach. METHODS AND RESULTS DES platforms have remarkable technical differences (side cell diameter, shape, deformability, etc.). We reviewed the literature data and performed original virtual bench tests to highlight the characteristics of DES platforms which influence the following phases of bifurcation stenting conducted according to the provisional approach: stent implantation in the main vessel across side-branch take-off ("crossover" stenting), proximal optimisation technique, rewiring and kissing balloon inflation. Available data show that the response of different DES platforms to the various procedural steps of provisional stenting is different. CONCLUSIONS When treating bifurcated lesions according to the provisional stenting approach, the search for an ideal matching between individual bifurcated anatomy and DES selection should take into account an articulated series of technical parameters.
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Affiliation(s)
- Francesco Burzotta
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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Stankovic G, Lefèvre T, Chieffo A, Hildick-Smith D, Lassen JF, Pan M, Darremont O, Albiero R, Ferenc M, Finet G, Adriaenssens T, Koo BK, Burzotta F, Louvard Y. Consensus from the 7th European Bifurcation Club meeting. EUROINTERVENTION 2013; 9:36-45. [DOI: 10.4244/eijv9i1a7] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Huo Y, Finet G, Lefevre T, Louvard Y, Moussa I, Kassab GS. Which diameter and angle rule provides optimal flow patterns in a coronary bifurcation? J Biomech 2012; 45:1273-9. [PMID: 22365499 DOI: 10.1016/j.jbiomech.2012.01.033] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 01/17/2012] [Accepted: 01/29/2012] [Indexed: 11/26/2022]
Abstract
The branching angle and diameter ratio in epicardial coronary artery bifurcations are two important determinants of atherogenesis. Murray's cubed diameter law and bifurcation angle have been assumed to yield optimal flows through a bifurcation. In contrast, we have recently shown a 7/3 diameter law (HK diameter model), based on minimum energy hypothesis in an entire tree structure. Here, we derive a bifurcation angle rule corresponding to the HK diameter model and critically evaluate the streamline flow through HK and Murray-type bifurcations. The bifurcations from coronary casts were found to obey the HK diameter model and angle rule much more than Murray's model. A finite element model was used to investigate flow patterns for coronary artery bifurcations of various types. The inlet velocity and pressure boundary conditions were measured by ComboWire. Y-bifurcation of Murray type decreased wall shear stress-WSS (10%-40%) and created an increased oscillatory shear index-OSI in atherosclerosis-prone regions as compared with HK-type bifurcations. The HK-type bifurcations were found to have more optimal flow patterns (i.e., higher WSS and lower OSI) than Murray-type bifurcations which have been traditionally believed to be optimized. This study has implications for changes in bifurcation angles and diameters in percutaneous coronary intervention.
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Affiliation(s)
- Yunlong Huo
- Department of Biomedical Engineering, IUPUI, Indianapolis, IN 46202, USA
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