BIOMECHANICAL CONSIDERATIONS IN THE DESIGN OF GRAFT: THE HOMEOSTASIS HYPOTHESIS

Mechanobiology of the endothelium in vascular health and disease: in vitro shear stress models

In recent years, there has been growing evidence that vascular pathologies arise in sites experiencing an altered haemodynamic environment. Fluid shear stress (FSS) is an important contributor to vascular homeostasis and regulates endothelial cell (EC) gene expression, morphology, and behaviour through specialised mechanosensitive signalling pathways. The presence of an altered FSS profile is a pathological characteristic of many vascular diseases, with the most established example being the preferential localisation of atherosclerotic plaque development. However, the precise haemodynamic contributions to other vascular pathologies including coronary artery vein graft failure remains poorly defined. To evaluate potential novel therapeutics for the treatment of vascular diseases via targeting EC behaviour, it is important to undertake in vitro experiments using appropriate culture conditions, particularly FSS. There are a wide range of in vitro models used to study the effect of FSS on the cultured endothelium, each with the ability to generate FSS flow profiles through which the investigator can control haemodynamic parameters including flow magnitude and directionality. An important consideration for selection of an appropriate model of FSS exposure is the FSS profile that the model can generate, in comparison to the physiological and pathophysiological haemodynamic environment of the vessel of interest. A resource bringing together the haemodynamic environment characteristic of atherosclerosis pathology and the flow profiles generated by in vitro methods of applying FSS would be beneficial to researchers when selecting the appropriate model for their research. Consequently, here we summarise the widely used methods of exposing cultured endothelium to FSS, the flow profile they generate and their advantages and limitations in investigating the pathological contribution of altered FSS to vascular disease and evaluating novel therapeutic targets for the treatment and prevention of vascular disease.

Acute Mechanical Consequences of Vessel-Specific Coronary Bypass Combinations

PURPOSE

Premature coronary artery bypass graft (CABG) failure has been linked to geometric, mechanical, and compositional discrepancies between host and graft tissues. Acute hemodynamic disturbances and the introduction of wall stress gradients trigger a myriad of mechanobiological processes at the anastomosis that can be associated with restenosis and graft failure. Although the origins of coronary artery disease dictate the anastomotic target, an opportunity exists for graft-vessel optimization through rationale graft selection.

METHODS

Here we explored the four distinct regions of the left (L) and right (R) ITA (1 = proximal, 2 = submuscular, 3 = middle, 4 = distal), and four common target vessels in the coronary circulation including the proximal and distal left anterior descending (PLAD & DLAD), right coronary (RCA), and left circumflex (LCX) arteries. Benchtop biaxial mechanical data was used to acquire constitutive model parameters of these tissues and enable vessel-specific computational models to elucidate the mechanical consequences of 32 unique graft-target combinations.

RESULTS

Simulations revealed the maximum principal wall stresses for the PLAD, RCA, and LCX occurred when anastomosed with LITA1, and the maximum flow-induced shear stress occurred with LITA4. The DLAD, on the other hand, reached stress maximums when anastomosed to LITA4. Using a normalized objective function of simulation output variables, we found LITA2 to be the best graft choice for both LADs, RITA3 for the RCA, and LITA3 for the LCX.

CONCLUSION

Although mechanical compatibility is just one of many factors determining bypass graft outcomes, our data suggests improvements can be made to the grafting process through vessel-specific regional optimization.

Advances in the development of tubular structures using extrusion-based 3D cell-printing technology for vascular tissue regenerative applications

Until recent, there are no ideal small diameter vascular grafts available on the market. Most of the commercialized vascular grafts are used for medium to large-sized blood vessels. As a solution, vascular tissue engineering has been introduced and shown promising outcomes. Despite these optimistic results, there are limitations to commercialization. This review will cover the need for extrusion-based 3D cell-printing technique capable of mimicking the natural structure of the blood vessel. First, we will highlight the physiological structure of the blood vessel as well as the requirements for an ideal vascular graft. Then, the essential factors of 3D cell-printing including bioink, and cell-printing system will be discussed. Afterwards, we will mention their applications in the fabrication of tissue engineered vascular grafts. Finally, conclusions and future perspectives will be discussed.

Structural design and mechanical performance of composite vascular grafts

This study reviews the state of the art in structural design and the corresponding mechanical behaviours of composite vascular grafts. We critically analyse surface and matrix designs composed of layered, embedded, and hybrid structures along the radial and longitudinal directions; materials and manufacturing techniques, such as tissue engineering and the use of textiles or their combinations; and the corresponding mechanical behaviours of composite vascular grafts in terms of their physical–mechanical properties, especially their stress–strain relationships and elastic recovery. The role of computational studies is discussed with respect to optimizing the geometrics designs and the corresponding mechanical behaviours to satisfy specialized applications, such as those for the aorta and its subparts. Natural and synthetic endothelial materials yield improvements in the mechanical and biological compliance of composite graft surfaces with host arteries. Moreover, the diameter, wall thickness, stiffness, compliance, tensile strength, elasticity, and burst strength of the graft matrix are determined depending on the application and the patient. For composite vascular grafts, hybrid architectures are recommended featuring multiple layers, dimensions, and materials to achieve the desired optimal flexibility and function for complying with user-specific requirements. Rapidly emerging artificial intelligence and big data techniques for diagnostics and the three-dimensional (3D) manufacturing of vascular grafts will likely yield highly compliant, subject-specific, long-lasting, and economical vascular grafts in the near-future.

Graphic abstract

A comparison of passive and active wall mechanics between elastic and muscular arteries of juvenile and adult rats

The elastic abdominal aorta and muscular femoral artery are susceptible to aneurysm and atherosclerosis, respectively. The vessel wall mechanics should be an important element for the difference. The objective of the study is to demonstrate a comparison of vessel wall mechanics between elastic and muscular arteries of juvenile and adult rats to show the changes of mechanical properties relevant to aging. The passive and active mechanical tests, theoretical analysis, and histological evaluation were carried out to investigate mechanical properties of vessel walls in the abdominal aorta and carotid and femoral arteries of young and adult rats. There are stiffening femoral artery, unchanged carotid artery, and distensible abdominal aorta in adult rats as compared with the young. The opening angle has values of 54 ± 13°, 82 ± 13°, and 94 ± 13° in the abdominal aorta and carotid and femoral arteries of adult rats, respectively, as well as 80 ± 22°, 93 ± 19°, and 100 ± 23° in the young. The findings are explained by the significantly reduced width of collagen fibers in the abdominal aorta, relatively unchanged width in the carotid artery, and significantly increased width in the femoral artery of adult rats as compared with the young. In conjunction with available literatures, we concluded that inconsistency for nonlinear age-related changes of artery wall mechanics occurs between arteries of different types, which may be a risk factor for the occurrence of abdominal aorta aneurysm and femoral artery atherosclerosis.

Evaluation of the Stress-Growth Hypothesis in Saphenous Vein Perfusion Culture

The great saphenous vein (GSV) has served as a coronary artery bypass graft (CABG) conduit for over 50 years. Despite prevalent use, first-year failure rates remain high compared to arterial autograft options. Amongst other factors, vein graft failure can be attributed to material and mechanical mismatching that lead to apoptosis, inflammation, and intimal-medial hyperplasia. Through the implementation of the continuum mechanical-based theory of "stress-mediated growth and remodeling," we hypothesize that the mechanical properties of porcine GSV grafts can be favorably tuned for CABG applications prior to implantation using a prolonged but gradual transition from venous to arterial loading conditions in an inflammatory and thrombogenic deficient environment. To test this hypothesis, we used a hemodynamic-mimetic perfusion bioreactor to guide remodeling through stepwise incremental changes in pressure and flow over the course of 21-day cultures. Biaxial mechanical testing of vessels pre- and post-remodeling was performed, with results fit to structurally-motivated constitutive models using non-parametric bootstrapping. The theory of "small-on-large" was used to describe appropriate stiffness moduli, while histology and viability assays confirmed microstructural adaptations and vessel viability. Results suggest that stepwise transition from venous-to-arterial conditions results in a partial restoration of circumferential stretch and circumferential, but not axial, stress through vessel dilation and wall thickening in a primarily outward remodeling process. These remodeled tissues also exhibited decreased mechanical isotropy and circumferential, but not axial, stiffening. In contrast, only increases in axial stiffness were observed using culture under venous perfusion conditions and those tissues experienced moderate intimal resorption.

Search for an Optimal Design of a Bioprosthetic Venous Valve: In silico and in vitro Studies

OBJECTIVE/BACKGROUND

Valve incompetence is a progressive disease of the venous system that may eventually lead to venous hypertension, pain, and ulcers. There is a need for a venous valve prosthesis to replace incompetent valves. Computational and experimental investigations on venous valve design and associated haemodynamics will undoubtedly advance prosthesis design and treatments. Here, the objective is to investigate the effect of venous valve on the fluid and solid mechanics. The hypothesis is that there exists a valve geometry that maximises leaflet shear stress (LSS) but minimises leaflet intramural stress (LIS; i.e., minimise stress ratio = LIS/LSS).

METHODS

To address the hypothesis, fully dynamic fluid-structure interaction (FSI) models were developed. The entire cycle of valve opening and closure was simulated. The flow validation experiments were conducted using a stented venous valve prosthesis and a pulse duplicator flow loop.

RESULTS

Agreement between the output of FSI simulations and output of pulse duplicator was confirmed. The maximum flow rates were within 6% difference, and the total flow during the cycle was within 10% difference. The simulated high stress ratio region at the leaflet base (five times the leaflet average) predicted the disease location of the vast majority of explanted venous valves reported in clinical literature. The study found that the reduced valve height and leaflet dome shape resulted in optimal performance to provide the lowest stress ratio.

CONCLUSION

This study proposes an effective design of venous prostheses and elaborates on the correlations of venous valve with clinical observations.

Design and analysis of a burst strength device for testing vascular grafts

The design and analysis of a device to measure the burst strength (strength under a state of pure radial internal pressure) and compliance of vascular grafts and flexible pressurized tubes is presented. The device comprises three main sections, viz., a clean air-dry pressure controller, a test specimen holder, and automated software for control and data collection. Air pressure is controlled by means of a valve and a dedicated mechanism allowing reaching up to 120 psi in increments of 1 psi, and recording pressure changes with 0.04 psi resolution. The circumferential strain is determined by measuring the radial displacement of the vascular graft using an optical arrangement capable of determining a maximum radial displacement of 10 mm with 0.02 mm resolution. The instrument provides a low uncertainty in compliance (±0.32%/100 mm Hg^-1) and burst strength measurements. Due to its simplicity, the device can easily be reproduced in other laboratories contributing to a dedicated instrument with high resolution at low cost. The reliability of the apparatus is further confirmed by conducting finite element analysis, elasticity solutions for pressurized cylinders, and testing of small diameter vascular grafts made of a commercial aliphatic polyurethane tested under radial internal pressure.

Application of Patient-Specific Computational Fluid Dynamics in Coronary and Intra-Cardiac Flow Simulations: Challenges and Opportunities

The emergence of new cardiac diagnostics and therapeutics of the heart has given rise to the challenging field of virtual design and testing of technologies in a patient-specific environment. Given the recent advances in medical imaging, computational power and mathematical algorithms, patient-specific cardiac models can be produced from cardiac images faster, and more efficiently than ever before. The emergence of patient-specific computational fluid dynamics (CFD) has paved the way for the new field of computer-aided diagnostics. This article provides a review of CFD methods, challenges and opportunities in coronary and intra-cardiac flow simulations. It includes a review of market products and clinical trials. Key components of patient-specific CFD are covered briefly which include image segmentation, geometry reconstruction, mesh generation, fluid-structure interaction, and solver techniques.

A comparison of postoperative morphometric and hemodynamic changes between saphenous vein and left internal mammary artery grafts

There is higher long‐term failure of the saphenous vein graft (SVG) compared with the left internal mammary artery (LIMA) graft, which is affected by the hemodynamic environment. A comprehensive analysis of postoperative structure‐function changes is important to study the atherogenesis in the SVG. A comparison of morphometric and hemodynamic parameters was carried out between LIMA grafts and SVGs and between different time points postoperatively. Various parameters were obtained from the image reconstruction and flow simulation in patients, who underwent CT exams for ~1 year, 5 and 10 years after revascularization. Morphometric data showed a decrease in lumen size in the entire SVG and anastomosis of different patients in a sequence of ~1 year, 5 and 10 years postoperatively despite negligible changes of LIMA size. Computational results indicated the fourfold increased surface area ratio (SAR) of low time‐averaged wall shear stress (TAWSS) in the SVG and anastomosis at postoperative 10 years than that at postoperative ~1 year. The SAR of high TAWSS gradient (TAWSSG) at the distal anastomosis between SVG and coronary arteries was significantly higher (14 ± 9% vs. 6 ± 8%) than that in the LIMA group at postoperative ~1 year. There were strong correlations between morphometric and hemodynamic parameters in the SVG and distal anastomosis at various time points postoperatively, which showed deterioration relevant to persistent diffuse diseases at postoperative ~10 years.

Vascular Mechanobiology: Towards Control of In Situ Regeneration

The paradigm of regenerative medicine has recently shifted from in vitro to in situ tissue engineering: implanting a cell-free, biodegradable, off-the-shelf available scaffold and inducing the development of functional tissue by utilizing the regenerative potential of the body itself. This approach offers a prospect of not only alleviating the clinical demand for autologous vessels but also circumventing the current challenges with synthetic grafts. In order to move towards a hypothesis-driven engineering approach, we review three crucial aspects that need to be taken into account when regenerating vessels: (1) the structure-function relation for attaining mechanical homeostasis of vascular tissues, (2) the environmental cues governing cell function, and (3) the available experimental platforms to test instructive scaffolds for in situ tissue engineering. The understanding of cellular responses to environmental cues leads to the development of computational models to predict tissue formation and maturation, which are validated using experimental platforms recapitulating the (patho)physiological micro-environment. With the current advances, a progressive shift is anticipated towards a rational and effective approach of building instructive scaffolds for in situ vascular tissue regeneration.

Pedicled Vein Grafts in Coronary Surgery: Perioperative Data From a Randomized Trial

BACKGROUND

Less-than-optimal long-term patency of the saphenous vein is one of the main obstacles for the success of coronary artery bypass grafting (CABG). Results from the IMPROVE-CABG trial has shown that harvesting the saphenous vein with a pedicle of perivascular tissue less than 5 mm while using manual distention provides comparable occlusion rates but significantly less intimal hyperplasia at early follow-up. The impact of pedicled veins on duration of operations, leg wound infections, and postoperative bleeding is unknown.

METHODS

One hundred patients undergoing first-time elective CABG were randomly assigned to conventional or pedicled vein harvesting. Perioperative and postoperative data were collected prospectively during the hospital stay and at follow-up.

RESULTS

Duration of extracorporeal circulation was significantly longer in the pedicled vein group (mean: 76 min versus 65 min, p = 0.006); however, no significant difference was found in the cross-clamp time. No significant difference was found in intraoperative vein graft flow, postoperative bleeding, or leg wound infections (4% in each group). No reoperations were due to vein graft bleeding.

CONCLUSIONS

Harvesting a pedicled vein provides comparable postoperative bleeding and leg wound infection rates in selected patients. The technique is associated with a slightly longer duration of extracorporeal circulation than harvesting conventional veins. Promising early results using the pedicled vein technique may contribute to a change in standard vein harvesting technique for CABG in selected patients.

PX-18 Protects Human Saphenous Vein Endothelial Cells under Arterial Blood Pressure

BACKGROUND

Arterial blood pressure-induced shear stress causes endothelial cell apoptosis and inflammation in vein grafts after coronary artery bypass grafting. As the inflammatory protein type IIA secretory phospholipase A₂ (sPLA₂-IIA) has been shown to progress atherosclerosis, we hypothesized a role for sPLA₂-IIA herein.

METHODS

The effects of PX-18, an inhibitor of both sPLA₂-IIA and apoptosis, on residual endothelium and the presence of sPLA₂-IIA were studied in human saphenous vein segments (n = 6) perfused at arterial blood pressure with autologous blood for 6 hrs.

RESULTS

The presence of PX-18 in the perfusion blood induced a significant 20% reduction in endothelial cell loss compared to veins perfused without PX18, coinciding with significantly reduced sPLA₂-IIA levels in the media of the vein graft wall. In addition, PX-18 significantly attenuated caspase-3 activation in human umbilical vein endothelial cells subjected to shear stress via mechanical stretch independent of sPLA₂-IIA.

CONCLUSIONS

In conclusion, PX-18 protects saphenous vein endothelial cells from arterial blood pressure-induced death, possibly also independent of sPLA₂-IIA inhibition.

Arterial Blood Pressure Induces Transient C4b-Binding Protein in Human Saphenous Vein Grafts

BACKGROUND

Complement is an important mediator in arterial blood pressure-induced vein graft failure. Previously, we noted activation of cell protective mechanisms in human saphenous veins too. Here we have analyzed whether C4b-binding protein (C4bp), an endogenous complement inhibitor, is present in the vein wall.

METHODS

Human saphenous vein segments obtained from patients undergoing coronary artery bypass grafting (n = 55) were perfused in vitro at arterial blood pressure with either autologous blood for 1, 2, 4, or 6 hr or with autologous blood supplemented with reactive oxygen species scavenger N-acetylcysteine. The segments were subsequently analyzed quantitatively for presence of C4bp and complement activation product C3d using immunohistochemistry.

RESULTS

Perfusion induced deposition of C3d and C4bp within the media of the vessel wall, which increased reproducibly and significantly over a period of 4 hr up to 3.8% for C3d and 81% for C4bp of the total vessel area. Remarkably after 6 hr of perfusion, the C3d-positive area decreased significantly to 1.3% and the C4bp-positive area to 19% of the total area of the vein. The areas positive for both C4bp and C3d were increased in the presence of N-acetylcysteine.

CONCLUSIONS

Exposure to arterial blood pressure leads to a transient presence of C4bp in the vein wall. This may be part of a cell-protective mechanism to counteract arterial blood pressure-induced cellular stress and inflammation in grafted veins.

Numerical analysis of Venous External Scaffolding Technology for Saphenous Vein Grafts

This paper presents a method for analyzing and comparing numerically Saphenous Vein Grafts (SVGs) following Coronary Artery Bypass Graft surgery (CABG). The method analyses the flow dynamics inside vein grafts with and without supporting using Venous External Scaffolding Technology (VEST). The numerical method uses patients׳ specific computational fluid dynamics (CFD) methods to characterize the relevant hemodynamic parameters of patients׳ SVGs. The method was used to compare the hemodynamics of six patient׳s specific model and flow conditions of stented and non-stented SVGs, 12 months post-transplantation. The flow parameters used to characterize the grafts׳ hemodynamics include Time Averaged Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI) and Relative Residence Time (RRT). The effect of stenting was clearly demonstrated by the chosen parameters. SVGs under constriction of VEST were associated with similar spatial average of TAWSS (10.73 vs 10.29 dyn/cm(2)), yet had fewer lesions with low TAWSS, lower OSI (0.041 vs 0.08) and RRT (0.12 vs 0.24), and more uniform flow with less flow discrepancies. In conclusion, the suggested method and parameters well demonstrated the advantage of VEST support. Stenting vein grafts with VEST improved hemodynamic factors which are correlated to graft failure following CABG procedure.

A Computational Model for Biomechanical Effects of Arterial Compliance Mismatch

Background. Compliance mismatch is a negative factor and it needs to be considered in arterial bypass grafting. Objective. A computational model was employed to investigate the effects of arterial compliance mismatch on blood flow, wall stress, and deformation. Methods. The unsteady blood flow was assumed to be laminar, Newtonian, viscous, and incompressible. The vessel wall was assumed to be linear elastic, isotropic, and incompressible. The fluid-wall interaction scheme was constructed using the finite element method. Results. The results show that there are identical wall shear stress waveforms, wall stress, and strain waveforms at different locations. The comparison of the results demonstrates that wall shear stresses and wall strains are higher while wall stresses are lower at the more compliant section. The differences promote the probability of intimal thickening at some locations. Conclusions. The model is effective and gives satisfactory results. It could be extended to all kinds of arteries with complicated geometrical and material factors.

Compliance properties of collagen-coated polyethylene terephthalate vascular prostheses

BACKGROUND

Compliance mismatch between native artery and a prosthetic graft used for infrainguinal bypass is said to be a factor for graft failure. The aim of this study was to develop a technique for measuring the compliance of collagen-coated polyethylene terephthalate (PET) vascular prostheses and to analyze the influence of several key properties on the elastic behavior of the grafts.

METHODS

Compliance testing was performed on 3 prostheses with and without internal compliant membrane (ICM). The principle of this test was to study the dimensional changes of prostheses submitted to internal pressure from 30 to 240 mm Hg at intervals of predetermined values.

RESULTS

We demonstrated that the ICM created links with the inner surface of the crimps and considerably modified the graft behavior when submitted to internal pressure. The results showed that compliance properties were dependent on the wall thickness and the crimping geometry of textile vascular prostheses. Mechanical analysis predicts the circumferential tensile behavior of these arterial grafts and validates tests for measuring compliance.

Hematocrit dispersion in asymmetrically bifurcating vascular networks

Quantitative modeling of physiological processes in vasculatures requires an accurate representation of network topology, including vessel branching. We propose a new approach for reconstruction of vascular network, which determines how vessel bifurcations distribute red blood cells (RBC) in the microcirculation. Our method follows the foundational premise of Murray's law in postulating the existence of functional optimality of such networks. It accounts for the non-Newtonian behavior of blood by allowing the apparent blood viscosity to vary with discharge hematocrit and vessel radius. The optimality criterion adopted in our approach is the physiological cost of supplying oxygen to the tissue surrounding a blood vessel. Bifurcation asymmetry is expressed in terms of the amount of oxygen consumption associated with the respective tissue volumes being supplied by each daughter vessel. The vascular networks constructed with our approach capture a number of physiological characteristics observed in in vivo studies. These include the nonuniformity of wall shear stress in the microcirculation, the significant increase in pressure gradients in the terminal sections of the network, the nonuniformity of both the hematocrit partitioning at vessel bifurcations and hematocrit across the capillary bed, and the linear relationship between the RBC flux fraction and the blood flow fraction at bifurcations.

INTIMAL HYPERPLASIA AND WALL SHEAR IN ARTERIAL BYPASS Y-GRAFTING AND CONSEQUENCE GRAFTING: A NUMERICAL STUDY

The progression of intimal hyperplasia is considered to be the main cause of bypass failure and is directly related to the individual blood rheology, local arterial geometry and placement of the junctions, graft diameter and graft surface characteristics as well as the degree of compliance. In this paper we use commercial computational fluid dynamics (CFD) ANSYS to examine under the correct physiological flow conditions the hemodynamic forces of composite bypass with internal mammary artery in Y-grafting and consequence grafting which is known to achieve high patency rate and highly recommended by clinicians. Particular emphasis is given here on the parameters that could initiate the development of intimal hyperplasia within these bypass configurations. The hemodynamic flow patterns between the consequence grafting and the composite Y-grafting are observed here to be different. Moreover, on both end-to-side and side-to-side configurations, the circulating flows are detected in the vicinity of the junction area, while the Dean flow vortexes are only observed on the end-to-side configuration. Likewise, the hemodynamic flow on the end-to-side configuration on the LCX of both 45° and 90° Y-grafting is found to be smoother than that of the junction on the LCA, regardless of the changing of anastomosis angles. The high WSS gradients are observed at the vicinity of the toe and on the bed of the junction, while the low WSS are presented at the distal of the stenosis and at the stagnation point. The clinical relevance of the results are presented and discussed with particular focus on the factors and the flow patterns that trigger the development of intimal hyperplasia.

Hemodynamic Shear Stress and Endothelial Dysfunction in Hemodialysis Access

Surgically-created blood conduits used for chronic hemodialysis, including native arteriovenous fistulas (AVFs) and synthetic AV grafts (AVGs), are the lifeline for kidney failure patients. Unfortunately, each has its own limitations: AVFs often fail to mature to become useful for dialysis and AVGs often fail due to stenosis as a result of neointimal hyperplasia, which preferentially forms at the graft-venous anastomosis. No clinical therapies are currently available to significantly promote AVF maturation or prevent neointimal hyperplasia in AVGs. Central to devising strategies to solve these problems is a complete mechanistic understanding of the pathophysiological processes. The pathology of arteriovenous access problems is likely multi-factorial. This review focuses on the roles of fluid-wall shear stress (WSS) and endothelial cells (ECs). In arteriovenous access, shunting of arterial blood flow directly into the vein drastically alters the hemodynamics in the vein. These hemodynamic changes are likely major contributors to non-maturation of an AVF vein and/or formation of neointimal hyperplasia at the venous anastomosis of an AVG. ECs separate blood from other vascular wall cells and also influence the phenotype of these other cells. In arteriovenous access, the responses of ECs to aberrant WSS may subsequently lead to AVF non-maturation and/or AVG stenosis. This review provides an overview of the methods for characterizing blood flow and calculating WSS in arteriovenous access and discusses EC responses to arteriovenous hemodynamics. This review also discusses the role of WSS in the pathology of arteriovenous access, as well as confounding factors that modulate the impact of WSS.

Numerical validation of pulse wave propagation: effects of arterial length

In this paper, the effects of arterial length on pulse wave propagation are presented to validate our fluid-structure interaction model. Three models, called the original, lengthened and shortened artery models, were obtained by changing arterial length. The results show that there is an obvious time delay between the velocity waveforms at two different locations in the original artery model, the same as the lengthened artery model. Furthermore, the velocity amplitude increases greatly in the two models. However the time delay cannot be seen clearly and the increase of the velocity amplitude is very small in the shortened artery model. There is a highest increase in the velocity amplitude of the lengthened artery model. The results indicate that arterial length plays an important role and give our model effective.

Mild anastomotic stenosis in patient-specific CABG model may enhance graft patency: a new hypothesis

It is well known that flow patterns at the anastomosis of coronary artery bypass graft (CABG) are complex and may affect the long-term patency. Various attempts at optimal designs of anastomosis have not improved long-term patency. Here, we hypothesize that mild anastomotic stenosis (area stenosis of about 40–60%) may be adaptive to enhance the hemodynamic conditions, which may contribute to slower progression of atherosclerosis. We further hypothesize that proximal/distal sites to the stenosis have converse changes that may be a risk factor for the diffuse expansion of atherosclerosis from the site of stenosis. Twelve (12) patient-specific models with various stenotic degrees were extracted from computed tomography images using a validated segmentation software package. A 3-D finite element model was used to compute flow patterns including wall shear stress (WSS) and its spatial and temporal gradients (WSS gradient, WSSG, and oscillatory shear index, OSI). The flow simulations showed that mild anastomotic stenosis significantly increased WSS (>15 dynes⋅cm⁻²) and decreased OSI (<0.02) to result in a more uniform distribution of hemodynamic parameters inside anastomosis albeit proximal/distal sites to the stenosis have a decrease of WSS (<4 dynes⋅cm⁻²). These findings have significant implications for graft adaptation and long-term patency.

High pulsatility flow stimulates smooth muscle cell hypertrophy and contractile protein expression

Proximal arterial stiffening is an important predictor of events in systemic and pulmonary hypertension, partly through its contribution to downstream vascular abnormalities. However, much remains undetermined regarding the mechanisms involved in the vascular changes induced by arterial stiffening. We therefore addressed the hypothesis that high pulsatility flow, caused by proximal arterial stiffening, induces downstream pulmonary artery endothelial cell (EC) dysfunction that in turn leads to phenotypic change of smooth muscle cells (SMCs). To test the hypothesis, we employed a model pulmonary circulation in which upstream compliance regulates the pulsatility of flow waves imposed onto a downstream vascular mimetic coculture composed of pulmonary ECs and SMCs. The effects of high pulsatility flow on SMCs were determined both in the presence and absence of ECs. In the presence of ECs, high pulsatility flow increased SMC size and expression of the contractile proteins, smooth muscle α-actin (SMA) and smooth muscle myosin heavy chain (SM-MHC), without affecting proliferation. In the absence of ECs, high pulsatility flow decreased SMC expression of SMA and SM-MHC, without affecting SMC size or proliferation. To identify the molecular signals involved in the EC-mediated SMC responses, mRNA and/or protein expression of vasoconstrictors [angiotensin-converting enzyme (ACE) and endothelin (ET)-1], vasodilator (eNOS), and growth factor (TGF-β1) in EC were examined. Results showed high pulsatility flow decreased eNOS and increased ACE, ET-1, and TGF-β1 expression. ACE inhibition with ramiprilat, ET-1 receptor inhibition with bosentan, and treatment with the vasodilator bradykinin prevented flow-induced, EC-dependent SMC changes. In conclusion, high pulsatility flow stimulated SMC hypertrophy and contractile protein expression by altering EC production of vasoactive mediators and cytokines, supporting the idea of a coupling between proximal vascular stiffening, flow pulsatility, and downstream vascular function.

Numerical analysis of coronary artery bypass grafts: an over view

Arterial bypass grafts tend to fail after some years due to the development of intimal thickening (restenosis). Non-uniform hemodynamics following a bypass operation contributes to restenosis and bypass failure can occur due to the focal development of anastomotic intimal hyperplasia. Additionally, surgical injury aggravated by compliance mismatch between the graft and artery has been suggested as an initiating factor for progress of wall thickening along the suture line Vascular grafts that are small in diameter tend to occlude rapidly. Computational fluid dynamics (CFD) methods have been effectively used to simulate the physical and geometrical parameters characterizing the hemodynamics of various arteries and bypass configurations. The effects of such changes on the pressure and flow characteristics as well as the wall shear stress during a cardiac cycle can be simulated. Recently, utilization of fluid and structure interactions have been used to determine fluid flow parameters and structure forces including stress and strains relationships under steady and transient conditions. In parallel to this, experimental diagnostics techniques such as Laser Doppler Anemometry, Particle Image Velocimetry, Doppler Guide wire and Magnetic Resonance Imaging have been used to provide essential information and to validate the numerical results. Moreover, clinical imaging techniques such as magnetic resonance or computed tomography have assisted considerably in gaining a detailed patient-specific picture of the blood flow and structure dynamics. This paper gives a review of recent numerical investigations of various configurations of coronary artery bypass grafts (CABG). In addition, the paper ends with a summary of the findings and the future directions.

Carotid circumferential wall stress homeostasis in early remodeling: theoretical approach and clinical application

PURPOSE

To assess the influence of cardiovascular risk factors on arterial wall growth and the remodeling process.

METHODS

In a theoretical part, we used a well-established relationship linking the rate of thickening of the arterial wall to the circumferential wall stress (CWS) increase. In a clinical part, we measured the intima-media thickness (IMT) in 166 subjects with increased cardiovascular risk score but no treatment for hypertension or hypercholesterolemia, no diabetes, and no cardiovascular disease. Far wall IMT and lumen diameter were measured along the right carotid artery by high-resolution ultrasonography and computerized image analysis.

RESULTS

A decreasing linear relationship between IMT and CWS was deduced from the theoretical model, implying that an increase in CWS would result in an IMT increase, and that the higher the IMT-CWS slope, the higher the thickening response. Subjects with advanced age, renal insufficiency, high 10-year Framingham risk, carotid atherosclerosis, and advanced atherosclerosis at other sites had sharper IMT-CWS slope (p < 0.05), in agreement with the homeostasis of CWS hypothesis.

CONCLUSIONS

The IMT increase responding to a CWS increase was greater in high-risk patients.

Uniform transmural strain in pre-stressed arteries occurs at physiological pressure

Residual deformation (strain) exists in arterial vessels, and has been previously proposed to induce homogeneous transmural strain distribution. In this work, we present analytical formulations that predict the existence of a finite internal (homeostatic) pressure for which the transmural deformation is homogenous, and the corresponding stress field. We provide evidence on the physical existence of homeostatic pressure when the artery is modeled as an incompressible tube with orthotropic constitutive strain-energy function. Based on experimental data of rabbit carotid arteries and porcine coronary arteries, the model predicts a homeostatic mean pressure of ~90 mmHg and 70-120 mmHg, respectively. The predictions are well within the physiological pressure range. Some consequences of this strain homogeneity in the physiological pressure range are explored under the proposed assumptions.

Mechanics and Function of the Pulmonary Vasculature: Implications for Pulmonary Vascular Disease and Right Ventricular Function

The relationship between cardiac function and the afterload against which the heart muscle must work to circulate blood throughout the pulmonary circulation is defined by a complex interaction between many coupled system parameters. These parameters range broadly and incorporate system effects originating primarily from three distinct locations: input power from the heart, hydraulic impedance from the large conduit pulmonary arteries, and hydraulic resistance from the more distal microcirculation. These organ systems are not independent, but rather, form a coupled system in which a change to any individual parameter affects all other system parameters. The result is a highly nonlinear system which requires not only detailed study of each specific component and the effect of disease on their specific function, but also requires study of the interconnected relationship between the microcirculation, the conduit arteries, and the heart in response to age and disease. Here, we investigate systems-level changes associated with pulmonary hypertensive disease progression in an effort to better understand this coupled relationship.

Mechanical stress as a regulator of cytoskeletal contractility and nuclear shape in embryonic epithelia

The mechano-sensitive responses of the heart and brain were examined in the chick embryo during Hamburger and Hamilton stages 10-12. During these early stages of development, cells in these structures are organized into epithelia. Isolated hearts and brains were compressed by controlled amounts of surface tension (ST) at the surface of the sample, and microindentation was used to measure tissue stiffness following several hours of culture. The response of both organs was qualitatively similar, as they stiffened under reduced loading. With increased loading, however, the brain softened while heart stiffness was similar to controls. In the brain, changes in nuclear shape and morphology correlated with these responses, as nuclei became more elliptical with decreased loading and rounder with increased loading. Exposure to the myosin inhibitor blebbistatin indicated that these changes in stiffness and nuclear shape are likely caused by altered cytoskeletal contraction. Computational modeling suggests that this behavior tends to return peak tissue stress back toward the levels it has in the intact heart and brain. These results suggest that developing cardiac and neural epithelia respond similarly to changes in applied loads by altering contractility in ways that tend to restore the original mechanical stress state. Hence, this study supports the view that stress-based mechanical feedback plays a role in regulating epithelial development.

Impact of competitive flow on wall shear stress in coronary surgery: computational fluid dynamics of a LIMA-LAD model

AIMS

Competitive flow from native coronary vessels is considered a major factor in the failure of coronary bypass grafts. However, the pathophysiological effects are not fully understood. Low and oscillatory wall shear stress (WSS) is known to induce endothelial dysfunction and vascular disease, like atherosclerosis and intimal hyperplasia. The aim was to investigate the impact of competitive flow on WSS in mammary artery bypass grafts.

METHODS AND RESULTS

Using computational fluid dynamics, WSS was calculated in a left internal mammary artery (LIMA) graft to the left anterior descending artery in a three-dimensional in vivo porcine coronary artery bypass graft model. The following conditions were investigated: high competitive flow (non-significant coronary lesion), partial competitive flow (significant coronary lesion), and no competitive flow (totally occluded coronary vessel). Time-averaged WSS of LIMA at high, partial, and no competitive flow were 0.3-0.6, 0.6-3.0, and 0.9-3.0 Pa, respectively. Further, oscillatory WSS quantified as the oscillatory shear index (OSI) ranged from (maximum OSI = 0.5 equals zero net WSS) 0.15 to 0.35, <0.05, and <0.05, respectively. Thus, high competitive flow resulted in substantial oscillatory and low WSS. Moderate competitive flow resulted in WSS and OSI similar to the no competitive flow condition.

CONCLUSION

Graft flow is highly dependent on the degree of competitive flow. High competitive flow was found to produce unfavourable WSS consistent with endothelial dysfunction and subsequent graft narrowing and failure. Partial competitive flow, however, may be better tolerated as it was found to be similar to the ideal condition of no competitive flow.

A systems approach to tissue remodeling

Remodeling of tissue in response to physical stress is a very complex process. The changes in the stimulus (cause) and response (effect) must be measured and the results must be organized into mathematical forms that are suitable for predictions and applications. An experiment where the stimulus (pressure, flow, shear stress, etc.) can be changed approximately as a step function (a step plus a perturbation) and the response (structure, material properties, function, etc.), which can be measured over time, can be simulated by indicial response functions (IRFs). The IRF is a mathematical expression of the ratio of the change in a particular feature of the system in response to a unit step change in stimulus. The IRF approach provides a quantitative description of the remodeling process, simplifies the interpretation of data, and greatly increases the potential of using the experimental data for prediction of the outcome for future experiments. The objective of this review is to provide an overview of the IRF approach including some exemplary systems. The goal is to illustrate how the indicial expressions make it possible to integrate biological complexity by convolution. The time courses of stimuli represent half of the convolution while the time course of changes in response represents the second half of the convolution. The IRF approach provides an understanding of the physiological problems with mathematical accuracy and may be conducive to new findings.

Physiologic compliance in engineered small-diameter arterial constructs based on an elastomeric substrate

Compliance mismatch is a significant challenge to long-term patency in small-diameter bypass grafts because it causes intimal hyperplasia and ultimately graft occlusion. Current engineered grafts are typically stiff with high burst pressure but low compliance and low elastin expression. We postulated that engineering small arteries on elastomeric scaffolds under dynamic mechanical stimulation would result in strong and compliant arterial constructs. This study compares properties of engineered arterial constructs based on biodegradable polyester scaffolds composed of either rigid poly(lactide-co-glycolide) (PLGA) or elastomeric poly(glycerol sebacate) (PGS). Adult baboon arterial smooth muscle cells (SMCs) were cultured in vitro for 10 days in tubular, porous scaffolds. Scaffolds were significantly stronger after culture regardless of material, but the elastic modulus of PLGA constructs was an order of magnitude greater than that of porcine carotid arteries and PGS constructs. Deformation was elastic in PGS constructs and carotid arteries but plastic in PLGA constructs. Compliance of arteries and PGS constructs were equivalent at pressures tested. Altering scaffold material from PLGA to PGS significantly decreased collagen content and significantly increased insoluble elastin content in constructs without affecting soluble elastin concentration in the culture medium. PLGA constructs contained no appreciable insoluble elastin. This research demonstrates that: (1) substrate stiffness directly affects in vitro tissue development and mechanical properties; (2) rigid materials likely inhibit elastin incorporation into the extracellular matrix of engineered arterial tissues; and (3) grafts with physiologic compliance and significant elastin content can be engineered in vitro after only days of cell culture.

Coronary Artery Bypass Grafting With Y-Saphenous Vein Grafts

Introduction: The saphenous vein is one of the indispensible grafts for coronary revascularization despite the advantages of arterial grafts over veins. It can be used in different configurations with different anastomosis (eg, sequential, composite, or Y-graft) techniques. Our aim was to investigate early and midterm results of Y-type anastomosis of saphenous vein grafts for complete coronary revascularization. Material and methods: Coronary artery bypass grafting (CABG) with Y-graft technique was performed in 512 patients between February 1998 and June 2007. In total, 608 saphenous Y coronary anastomoses were performed. These anastomoses were on first and second obtuse marginal arteries (n: 323), first diagonal and first obtuse marginal arteries (n: 187), posterolateral and posterior descending artery (n: 79), and right coronary artery and posterior descending artery (n: 19). Endareterectomy was performed in 28 patients with severely calcified coronary arteries. Patients were evaluated for early and late survival, newly developing cardiac events, recurring angina, and reinterventions. Results: In the early postoperative period, new myocardial infarction (MI) occurred in 27 (5.2%) patients and mortality in 13 (2.5%). Follow-up included the results of 487 (98%) patients. Mean follow-up duration was 56 ± 24 months. Late mortality occurred in 36 (7.3%) patients, and in 13 (2.6%) patients new MI developed in the remote follow-up. Overall survival including all deaths at 3, 5, and 7 years was 94 ± 0.6%, 86 ± 1.3%, and 83 ± 2.1%, respectively, and actuarial freedom from angina recurrence at 3, 5, and 7 years was 95.2 ± 2.5%, 86.4 ± 3%, and 84.7 ± 4.6%, respectively. Among long-term survivors, 116 patients (25.7%), 49 being symptomatic, with 123 saphenous Y-type anastomoses having undergone angiography studies. Saphenous vein Y grafts were completely patent in 94 anastomoses (76.4%). Conclusions: Saphenous vein Y-type anastomosis technique can safely be used in patients with multivessel coronary artery disease (CAD) with successful long-term outcomes. As with sequential anastomosis, the safety of the technique may be attributed to the distribution of inflow from aorta into multiple vessels.

Correction of carotid intima-media thickness for adaptive dependence on tensile stress: implication for cardiovascular risk assessment

PURPOSE

Early artery wall-thickening detected by ultrasound-assessed increased carotid intima-media thickness (IMT) may reflect atherosclerosis or represent an adaptive response to keep homeostasis tensile stress that is related inversely to wall thickness by Laplace's equation. We attempted to discriminate between both mechanisms by correcting IMT for its inverse association with tensile stress.

METHODS

Common carotid IMT and lumen diameter (D) where determined in 40 healthy controls and 119 never-treated asymptomatic patients with >or=1 traditional cardiovascular risk factor. The cross-sectional area (CSA) was calculated as pi x IMT x (IMT + D). Tensile stress was approximated by [mean blood pressure x (D/2 x IMT)], and wall shear stress by [(blood viscosity) x 4 x (mean blood velocity/D)]. Inverse regression line relating IMT and tensile stress in controls (p < 0.001) was used as a reference to determine in an individual at-risk patient the IMT deviation, defining DeltaIMT from the regression line of controls at the measured patient's tensile stress.

RESULTS

DeltaIMT correlated positively with age (p < 0.05), body mass index (p < 0.05), blood pressure (p < 0.001), and glucose (p < 0.001). In multivariate analysis, DeltaIMT was independently associated with age (p < 0.01), male gender (p < 0.001), and blood pressure (p < 0.001). IMT showed positive association with age (p < 0.001) but not with other risk factors. Also, DeltaIMT, like CSA, correlated positively with tensile stress (p < 0.001) and negatively with wall shear stress (p < 0.05, p < 0.01), whereas IMT correlated negatively with tensile stress (p < 0.001) but not with wall shear stress.

CONCLUSION

Correcting IMT for adaptive association with tensile stress may give more strength to carotid evaluation for assessing cardiovascular risk.

Wall thickness of coronary vessels varies transmurally in the LV but not the RV: implications for local stress distribution

Since the right and left ventricles (RV and LV) function under different loading conditions, it is not surprising that they differ in their mechanics (intramyocardial pressure), structure, and metabolism; such differences may also contribute to differences in the coronary vessel wall. Our hypothesis is that intima-media thickness (IMT), IMT-to-radius (IMT-to-R) ratio, and vessel wall stress vary transmurally in the LV, much more than in the RV. Five normal Yorkshire swine were used in this study. The major coronary arteries were cannulated through the aorta and perfusion fixed with 6.25% glutaraldehyde and casted with a catalyzed silicone-elastomer solution. Arterial and venous vessels were obtained from different transmural locations of the RV and LV, processed for histological analysis, and measured with an imaging software. A larger transmural gradient was found for IMT, IMT-to-R ratio, and diastolic circumferential stress in vessels from the LV than the nearly zero transmural slope in the RV. The IMT of arterial vessels in the LV showed a slope of 0.7 +/- 0.5 compared with 0.3 +/- 0.3 of arterial vessels in the RV (P <or= 0.05). The slope for venous vessels in the LV was 0.14 +/- 0.14 vs. 0.06 +/- 0.05 in the RV. The present data reflect the local structure-function relation, where the significant gradient in intramyocardial pressure in the LV is associated with a significant gradient of IMT and IMT-to-R ratio, unlike the RV. This has important implications for local adaptation of transmural loading on the vessel wall and vascular remodeling when the loading is perturbed in cardiac hypertrophy or heart failure.

Low wall shear stress predicts subsequent development of wall hypertrophy in lower limb bypass grafts

Background

Venous grafts commonly develop myointimal hyperplasia, which can lead to stenoses and, ultimately, with expression of adhesion molecules, lumenal occlusion. The aim of the present study was to investigate whether wall shear stress measured post-operatively would predict subsequent myointimal hypertrophy in lower limb venous bypass grafts.

Methods

Magnetic resonance imaging and ultrasound were performed in a cohort of patients following lower limb venous bypass graft surgery for peripheral arterial disease at baseline (1-2 weeks) and at follow-up (9-12 months). Wall shear stress was determined at baseline using computational fluid dynamics techniques and intima-media thickness along the length of the graft was measured by ultrasound at baseline and follow up.

Results

Complete follow-up was possible in eight patients, in whom low wall shear stress at baseline predicted high intima-media thickness. The relationship between wall shear stress (WSS) and intima-media thickness (IMT) was curvilinear with IMT increasing sharply at lower levels of WSS (IMT >1.0 mm at <0.3 Pa).

Conclusions

Low wall shear stress is associated with subsequent increase in myointimal thickness in lower limb venous bypass grafts. This is believed to be the first prospective study in humans to demonstrate the relationship between low wall shear stress and myointimal thickening and indicates a likely causative role for low wall shear stress in the development of myointimal hyperplasia.

An analysis of the strain field in biaxial Flexcell membranes for different waveforms and frequencies

Mechanical stimuli have been shown to affect cell behaviour in terms of proliferation, apoptosis, and protein expression. In terms of cardiovascular diseases, for example, endothelial and smooth muscle cells exposed to an abnormal strain environment have been associated with atherosclerosis and in-stent restenosis. The FX-4000™ system (Flexercell® Tension Plus System, Flexcell Corporation, McKeesport, Pennsylvania, USA) is an in-vitro system that is widely used to strain cells in order to evaluate their response to strain. The precision, accuracy, and repeatability of the strains controlled by the system are therefore crucial to analyse and interpret the results confidently. The aim of this study was to investigate the mechanical behaviour of the FX-4000™ Flexercell® six-well-plate silicon membranes for static and dynamic cyclic strains by measuring the maximum peak strain and analysing the change in the membrane deformation after cyclic strain for 0 h, 24 h, and 48 h at different strain amplitudes and frequencies. The results of the tests conducted demonstrate notable differences between the measured strains of the membranes in comparison with both the inputs and the outputs of the Flexcell® software. The calibration method used by Flexcell® International assumes that the strain values determined for a given vacuum pressure on the silicone membranes are reliable for different waveforms and frequencies. The data reported here clearly indicate that this is not the case. The results indicate that a unique calibration pressure—strain curve must be determined for each test given the viscoelastic nature of the Flexcell system. A new method to calibrate the machine in house was applied using new pressure—strain equations. This new calibration method has been presented and should enable researchers using the Flexcell® machine to set up their cell experiments more accurately.

NADPH oxidase has a directional response to shear stress

Vessel regions with predilection to atherosclerosis have negative wall shear stress due to flow reversal. The flow reversal causes the production of superoxides (O(2)(-)), which scavenge nitric oxide (NO), leading to a decrease in NO bioavailability and endothelial dysfunction. Here, we implicate NADPH oxidase as the primary source of O(2)(-) during full flow reversal. Nitrite production and the degree of vasodilation were measured in 46 porcine common femoral arteries in an ex vivo system. Nitrite production and vasodilation were determined before and after the inhibition of NADPH oxidase, xanthine oxidase, or mitochondrial oxidase. NADPH oxidase inhibition with gp91ds-tat or apocynin restored nitrite production and vasodilation during reverse flow. Xanthine oxidase inhibition increased nitrite production at the highest flow rate, whereas mitochondrial oxidase inhibition had no effect. These findings suggest that the NADPH oxidase system can respond to directional changes of flow and is activated to generate O(2)(-) during reverse flow in a dose-dependent fashion. These findings have important clinical implications for oxidative balance and NO bioavailability in regions of flow reversal in a normal and compromised cardiovascular system.

Determination of homeostatic elastic moduli in two layers of the esophagus

The function of the esophagus is mechanical. To understand the function, it is necessary to know how the stress and strain in the esophagus can be computed, and how to determine the stress-strain relationship of the wall materials. The present article is devoted to the issue of determining the incremental elastic moduli in the layers of the esophagus under homeostatic conditions. The esophagus is treated as a two-layered structure consisting of an inner collagen-rich submucosa layer and an outer muscle layer. We adopt a theory based on small perturbation experiments at homeostatic conditions for determination of incremental moduli in circumferential, axial, and cross directions in the two layers. The experiments are inflation, axial stretching, circumferential bending, and axial bending. The analysis takes advantage of knowing the esophageal zero-stress state (an open sector with an opening angle of 59.4 +/- 13.2 deg). The neutral axis was located 27% +/- 1.9%away from the mucosal surface. It is demonstrated that under homeostatic conditions, the incremental moduli are layer and direction dependent. The incremental modulus is the highest in the axial direction. Furthermore, the axial moduli for the two layers are similar, whereas in the circumferential direction, the incremental modulus is a factor of 6 higher in the mucosa-submucosa layer compared to the muscle layer. Hence, the esophagus has to be treated as a composite, anisotropic body. With this additional information, we can then look forward to a vision of truly understanding the mechanical events of the esophagus.