Influence of surrounding tissues on biomechanics of aortic wall

Quantification of the heterogeneous effect of static and dynamic perivascular structures on patient-specific local aortic wall mechanics using inverse finite element modeling and DENSE MRI

Recent studies have highlighted the relevance of perivascular interactions on aortic wall mechanics. Most of the approaches assume static perivascular structures; however, the beating heart dynamically displaces the neighboring aorta. We develop a model to account for the effect of periaortic interactions due to static and dynamic structures by prescribing a moving elastic foundation boundary condition (EFBC) embedded into an inverse finite element algorithm using in vivo displacements from 2D displacement encoding with stimulated echoes (DENSE) MRI as target data. We applied this method at three different locations of interest, the distal aortic arch (DAA), descending thoracic aorta (DTA), and infrarenal abdominal aorta (IAA) for a total of 27 cases in healthy humans. The model reproduces the target diastole-to-systole deformation and bulk displacement of the aortic wall with median displacement errors below 0.5mm. The EFBC showed good agreement with the location of anatomical features and was consistent among individuals of similar characteristics. Results show that an energy source acting on the adventitia is required to reproduce the displacements measured at the vicinity of the heart, but not at the abdomen. The average adventitial load as a percentage of the luminal pulse-pressure was found to increase with age and to decrease along the descending aorta, from 61% at the DAA to 37% at the DTA, and 30% at the IAA. This approach offers a patient-specific method to estimate in vivo adventitial loads and aortic wall stiffness, which can bring a better understanding of normal and pathological in vivo aortic function.

Harmonic Distortion of Blood Pressure Waveform as a Measure of Arterial Stiffness

Aging and disease alter the composition and elastic properties of the aortic wall resulting in shape changes in blood pressure waveform (BPW). Here, we propose a new index, harmonic distortion (HD), to characterize BPW and its relationship with other in vitro and in vivo measures. Using a Fourier transform of the BPW, HD is calculated as the ratio of energy above the fundamental frequency to that at the fundamental frequency. Male mice fed either a normal diet (ND) or a high fat, high sucrose (HFHS) diet for 2–10 months were used to study BPWs in diet-induced metabolic syndrome. BPWs were recorded for 20 s hourly for 24 h, using radiotelemetry. Pulse wave velocity (PWV), an in vivo measure of arterial stiffness, was measured in the abdominal aorta via ultrasound sonography. Common carotid arteries were excised from a subset of mice to determine the tangent modulus using biaxial tension-inflation test. Over a 24-h period, both HD and systolic blood pressure (SBP) show a large variability, however HD linearly decreases with increasing SBP. HD is also linearly related to tangent modulus and PWV with slopes significantly different between the two diet groups. Overall, our study suggests that HD is sensitive to changes in blood pressure and arterial stiffness and has a potential to be used as a noninvasive measure of arterial stiffness in aging and disease.

Aortic stiffness is lower when perivascular adipose tissue (PVAT) is included: a novel ex vivo mechanics study

Perivascular adipose tissue (PVAT) is increasingly recognized as an essential layer of the functional vasculature, being responsible for producing vasoactive substances and assisting arterial stress relaxation. Here we test the hypothesis that PVAT reduces aortic stiffness. Our model was the thoracic aorta of the male Sprague Dawley rat. Uniaxial mechanical tests for three groups of tissue were performed: aorta +PVAT (+PVAT), aorta - PVAT (-PVAT), and isolated PVAT (PVAT only). The output of the mechanical test is reported in the form of a Cauchy stress-stretch curve. This work presents a novel, physiologically relevant approach to measure mechanical stiffness ex vivo in isolated PVAT. Low-stress stiffness (), high-stress stiffness (), and the stress corresponding to a stretch of 1.2 () were measured as metrics of distensibility. The low-stress stiffness was largest in the -PVAT samples and smallest in PVAT only samples. Both the high-stress stiffness and the stress at 1.2 stretch were significantly higher in -PVAT samples when compared to +PVAT samples. Taken together these results suggest that -PVAT samples are stiffer (less distensible) both at low stress (not significant) as well as at high stress (significant) when compared to +PVAT samples. These conclusions are supported by the results of the continuum mechanics material model we also used to interpret the same experimental data. Thus, tissue stiffness is significantly lower when considering PVAT as part of the aortic wall. As such, PVAT should be considered as a target for improving vascular function in diseases with elevated aortic stiffness, including hypertension.

3D finite-element modeling of vascular adaptation after endovascular aneurysm repair

Aneurysm shrinkage is clinically observed after successful endovascular aortic aneurysm repair (EVAR). However, global understanding of post-operative aneurysm evolutions remains weak. In this work, we propose to study these effects using numerical simulation. We set up a 3D finite-element model of post-EVAR vascular adaptation within an open-source finite-element code, which was initially developed for growth and remodeling (G&R). We modeled the endograft with a set of uniaxial prestrained springs that apply radial forces on the inner surface of the artery. Constitutive equations, momentum balance equations, and equations related to the mechanobiology of the artery were formulated based on the homogenized constrained mixture theory. We performed a sensitivity analysis by varying different selected parameters, namely oversizing and compliance of the stent-graft, gain parameters related to collagen G&R, and the residual pressure in the aneurysm sac. This permitted us to evaluate how each factor influences post-EVAR vascular adaptation. It was found that oversizing, compliance or gain parameters have a limited influence compared to that of the residual pressure in the aneurysm sac, which was found to play a critical role in the stability of aneurysm after stent-graft implantation. An excessive residual pressure larger than 50 mmHg can induce a continuous expansion of the aneurysm while a moderate residual pressure below this critical threshold yields continuous shrinkage of the aneurysm. Moreover, it was found that elderly patients, with relatively lower amounts of remnant elastin in the arterial wall, are more sensitive to the effect of residual pressure. Therefore, these results show that elderly patients may present a higher potential risk of aortic sac expansion due to intra-aneurysm sac pressure after EVAR than younger patients.

Stress Analysis in AAA does not Predict Rupture Location Correctly in Patients with Intraluminal Thrombus

BACKGROUND

A biomechanical approach to the rupture risk of an abdominal aortic aneurysm could be a solution to ensure a personalized estimate of this risk. It is still difficult to know in what conditions, the assumptions made by biomechanics, are valid. The objective of this work was to determine the individual biomechanical rupture threshold and to assess the correlation between their rupture sites and the locations of their maximum stress comparing two computed tomography scan (CT) before and at time of rupture.

METHODS

We included 5 patients who had undergone two CT; one within the last 6 months period before rupture and a second CT scan just before the surgical procedure for the rupture. All DICOM data, both pre- and rupture, were processed following the same following steps: generation of a 3D geometry of the abdominal aortic aneurysm, meshing and computational stress analysis using the finite element method. We used two different modelling scenarios to study the distribution of the stresses, a "wall" model without intraluminal thrombus (ILT) and a "thrombus" model with ILT.

RESULTS

The average time between the pre-rupture and rupture CT scans was 44 days (22-97). The median of the maximum stresses applied to the wall between the pre-rupture and rupture states were 0.817 MPa (0.555-1.295) and 1.160 MPa (0.633-1.625) for the "wall" model; and 0.365 MPa (0.291-0.753) and 0.390 MPa (0.343-0.819) for the "thrombus" model. There was an agreement between the site of rupture and the location of maximum stress for only 1 patient, who was the only patient without ILT.

CONCLUSIONS

We observed a large variability of stress values at rupture sites between patients. The rupture threshold strongly varied between individuals depending on the intraluminal thrombus. The site of rupture did not correlate with the maximum stress except for 1 patient.

Blood pressure changes PVAT function and transcriptome: use of the mid-thoracic aorta coarcted rat

Perivascular adipose tissue (PVAT) modifies the contractile function of the vessel it surrounds (outside-in signaling). Little work points to the vessel actively affecting its surrounding PVAT. We hypothesized that inside-out arterial signaling to PVAT would be evidenced by the response of PVAT to changes in tangential vascular wall stress. Rats coarcted in the mid-thoracic aorta created PVAT tissues that would exemplify pressure-dependent changes (above vs. below coarctation); a sham rat was used as a control. Radiotelemetry revealed a ∼20 mmHg systolic pressure gradient across the coarctation 4 wk after surgery. Four measures (histochemical, adipocyte progenitor proliferation and differentiation, isometric tone, and bulk mRNA sequencing) were used to compare PVAT above versus below the ligature in sham and coarcted rats. Neither aortic collagen deposition in PVAT nor arterial media/radius ratio above coarctation was increased versus below segments. However, differentiated adipocytes derived from PVAT above the coarctation accumulated substantially less triglycerides versus those below; their relative proliferation rate as adipogenic precursors was not different. Functionally, the ability of PVAT to assist stress relaxation of isolated aorta was reduced in rings above versus below the coarctation. Transcriptomic analyses revealed that the coarctation resulted in more differentially expressed genes (DEGs) between PVAT above versus below when compared with sham samples from the same locations. A majority of DEGs were in PVAT below the coarctation and were enriched in neuronal/synaptic terms. These findings provide initial evidence that signaling from the vascular wall, as stimulated by a pressure change, influences the function and transcriptional profile of its PVAT.NEW & NOTEWORTHY A mid-thoracic aorta coarcted rat was created to generate a stable pressure difference above versus below the coarctation ligature. This study determined that the PVAT around the thoracic aorta exposed to a higher pressure has a significantly reduced ability to assist stress relaxation versus that below the ligature and appears to retain the ability to be anticontractile. At the same time, the PVAT around the thoracic aorta exposed to higher pressure had a reduced adipogenic potential versus that below the ligature. Transcriptomics analyses indicated that PVAT below the coarctation showed the greatest number of DEGs with an increased profile of the synaptic neurotransmitter gene network.

Anthropomorphic and biomechanical mockup for abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is an asymptomatic condition due to the dilation of abdominal aorta along with progressive wall degeneration, where rupture of AAA is life-threatening. Failures of AAA endovascular repair (EVAR) reflect our inadequate knowledge about the complex interaction between the aortic wall and medical devices. In this regard, we are presenting a hydrogel-based anthropomorphic mockup (AMM) to better understand the biomechanical constraints during EVAR. By adjusting the cryogenic treatments, we tailored the hydrogel to mimic the mechanical behavior of human AAA wall, thrombus and abdominal fat. A specific molding sequence and a pressurizing system were designed to reproduce the geometrical and diseased characteristics of AAA. A mechanically, anatomically and pathologically realistic AMM for AAA was developed for the first time, EVAR experiments were then performed with and without the surrounding fat. Substantial displacements of the aortic centerlines and vessel expansion were observed in the case without surrounding fat, revealing an essential framework created by the surrounding fat to account for the interactions with medical devices. In conclusion, the importance to consider surrounding tissue for the global deformation of AAA during EVAR was highlighted. Furthermore, potential use of this AMM for medical training was also suggested.

An in vivo parameter identification method for arteries: numerical validation for the human abdominal aorta

A method for identifying mechanical properties of arterial tissue in vivo is proposed in this paper and it is numerically validated for the human abdominal aorta. Supplied with pressure-radius data, the method determines six parameters representing relevant mechanical properties of an artery. In order to validate the method, 22 finite element arteries are created using published data for the human abdominal aorta. With these in silico abdominal aortas, which serve as mock experiments with exactly known material properties and boundary conditions, pressure-radius data sets are generated and the mechanical properties are identified using the proposed parameter identification method. By comparing the identified and pre-defined parameters, the method is quantitatively validated. For healthy abdominal aortas, the parameters show good agreement for the material constant associated with elastin and the radius of the stress-free state over a large range of values. Slightly larger discrepancies occur for the material constants associated with collagen, and the largest relative difference is obtained for the in situ axial prestretch. For pathological abdominal aortas incorrect parameters are identified, but the identification method reveals the presence of diseased aortas. The numerical validation indicates that the proposed parameter identification method is able to identify adequate parameters for healthy abdominal aortas and reveals pathological aortas from in vivo-like data.

Manufacturing Abdominal Aorta Hydrogel Tissue-Mimicking Phantoms for Ultrasound Elastography Validation

Ultrasound (US) elastography, or elasticity imaging, is an adjunct imaging technique that utilizes sequential US images of soft tissues to measure the tissue motion and infer or quantify the underlying biomechanical characteristics. For abdominal aortic aneurysms (AAA), biomechanical properties such as changes in the tissue's elastic modulus and estimates of the tissue stress may be essential for assessing the need for the surgical intervention. Abdominal aortic aneurysms US elastography could be a useful tool to monitor AAA progression and identify changes in biomechanical properties characteristic of high-risk patients. A preliminary goal in the development of an AAA US elastography technique is the validation of the method using a physically relevant model with known material properties. Here we present a process for the production of AAA tissue-mimicking phantoms with physically relevant geometries and spatially modulated material properties. These tissue phantoms aim to mimic the US properties, material modulus, and geometry of the abdominal aortic aneurysms. Tissue phantoms are made using a polyvinyl alcohol cryogel (PVA-c) and molded using 3D printed parts created using computer aided design (CAD) software. The modulus of the phantoms is controlled by altering the concentration of PVA-c and by changing the number of freeze-thaw cycles used to polymerize the cryogel. The AAA phantoms are connected to a hemodynamic pump, designed to deform the phantoms with the physiologic cyclic pressure and flows. Ultra sound image sequences of the deforming phantoms allowed for the spatial calculation of the pressure normalized strain and the identification of mechanical properties of the vessel wall. Representative results of the pressure normalized strain are presented.

Combining in vivo and in vitro biomechanical data reveals key roles of perivascular tethering in central artery function

Considerable insight into effectors of cardiovascular function can be gleaned from controlled studies on mice, especially given the diverse models that are available. Toward this end, however, there is a need for consistent and complementary methods of in vivo and in vitro data analysis, synthesis, and interpretation. The overall objective of this study is twofold. First, we present new semi-automated methods to quantify in vivo measurements of vascular function in anesthetized mice as well as new approaches to synthesize these data with those from in vitro biaxial mechanical characterizations. Second, we contrast regional differences in biomechanical behaviors along the central vasculature by combining biaxial strains measured in vivo with data on the unloaded geometry and biaxial material properties measured in vitro. Results support the hypothesis that the healthy ascending aorta stores significant elastic energy during systole, which is available to work on the heart and blood during diastole, particularly during periods of physical exertion, and further suggest that perivascular tethering allows arteries to work at lower values of wall stress and material stiffness than often assumed. The numerous measurements of vascular function and properties provided herein can also serve as reference values for normal wild-type male and female mice, to which values for myriad genetic, surgical, and pharmacological models can be compared in future studies.

Population-specific material properties of the implantation site for transcatheter aortic valve replacement finite element simulations

Patient-specific computational models are an established tool to support device development and test under clinically relevant boundary conditions. Potentially, such models could be used to aid the clinical decision-making process for percutaneous valve selection; however, their adoption in clinical practice is still limited to individual cases. To be fully informative, they should include patient-specific data on both anatomy and mechanics of the implantation site. In this work, fourteen patient-specific computational models for transcatheter aortic valve replacement (TAVR) with balloon-expandable Sapien XT devices were retrospectively developed to tune the material parameters of the implantation site mechanical model for the average TAVR population. Pre-procedural computed tomography (CT) images were post-processed to create the 3D patient-specific anatomy of the implantation site. Balloon valvuloplasty and device deployment were simulated with finite element (FE) analysis. Valve leaflets and aortic root were modelled as linear elastic materials, while calcification as elastoplastic. Material properties were initially selected from literature; then, a statistical analysis was designed to investigate the effect of each implantation site material parameter on the implanted stent diameter and thus identify the combination of material parameters for TAVR patients. These numerical models were validated against clinical data. The comparison between stent diameters measured from post-procedural fluoroscopy images and final computational results showed a mean difference of 2.5 ± 3.9%. Moreover, the numerical model detected the presence of paravalvular leakage (PVL) in 79% of cases, as assessed by post-TAVR echocardiographic examination. The final aim was to increase accuracy and reliability of such computational tools for prospective clinical applications.

Detecting Regional Stiffness Changes in Aortic Aneurysmal Geometries Using Pressure-Normalized Strain

Transabdominal ultrasound elasticity imaging could improve the assessment of rupture risk for abdominal aortic aneurysms by providing information on the mechanical properties and stress or strain states of vessel walls. We implemented a non-rigid image registration method to visualize the pressure-normalized strain within vascular tissues and adapted it to measure total strain over an entire cardiac cycle. We validated the algorithm's performance with both simulated ultrasound images with known principal strains and anatomically accurate heterogeneous polyvinyl alcohol cryogel vessel phantoms. Patient images of abdominal aortic aneurysm were also used to illustrate the clinical feasibility of our imaging algorithm and the potential value of pressure-normalized strain as a clinical metric. Our results indicated that pressure-normalized strain could be used to identify spatial variations in vessel tissue stiffness. The results of this investigation were sufficiently encouraging to warrant a clinical study measuring abdominal aortic pressure-normalized strain in a patient population with aneurysmal disease.

Can finite element models of ballooning procedures yield mechanical response of the cardiovascular site to overexpansion?

Patient-specific numerical models could aid the decision-making process for percutaneous valve selection; in order to be fully informative, they should include patient-specific data of both anatomy and mechanics of the implantation site. This information can be derived from routine clinical imaging during the cardiac cycle, but data on the implantation site mechanical response to device expansion are not routinely available.

We aim to derive the implantation site response to overexpansion by monitoring pressure/dimensional changes during balloon sizing procedures and by applying a reverse engineering approach using a validated computational balloon model. This study presents the proof of concept for such computational framework tested in-vitro. A finite element (FE) model of a PTS-X405 sizing balloon (NuMed, Inc., USA) was created and validated against bench tests carried out on an ad hoc experimental apparatus: first on the balloon alone to replicate free expansion; second on the inflation of the balloon in a rapid prototyped cylinder with material deemed suitable for replicating pulmonary arteries in order to validate balloon/implantation site interaction algorithm.

Finally, the balloon was inflated inside a compliant rapid prototyped patient-specific right ventricular outflow tract to test the validity of the approach. The corresponding FE simulation was set up to iteratively infer the mechanical response of the anatomical model. The test in this simplified condition confirmed the feasibility of the proposed approach and the potential for this methodology to provide patient-specific information on mechanical response of the implantation site when overexpanded, ultimately for more realistic computational simulations in patient-specific settings.

The role of perivascular adipose tissue in vasoconstriction, arterial stiffness, and aneurysm

Since the "rediscovery" of brown adipose tissue in adult humans, significant scientific efforts are being pursued to identify the molecular mechanisms to promote a phenotypic change of white adipocytes into brown-like cells, a process called "browning". It is well documented that white adipose tissue (WAT) mass and factors released from WAT influence the vascular function and positively correlate with cardiac arrest, stroke, and other cardiovascular complications. Similar to other fat depots, perivascular adipose tissue (PVAT) is an active endocrine organ and anatomically surrounds vessels. Both brown-like and white-like PVAT secrete various adipokines, cytokines, and growth factors that either prevent or promote the development of cardiovascular diseases (CVDs) depending on the relative abundance of each type and their bioactivity in the neighboring vasculature. Notably, pathophysiological conditions, such as obesity, hypertension, or diabetes, induce the imbalance of PVAT-derived vasoactive products that promote the infiltration of inflammatory cells. This then triggers derangements in vascular smooth muscle cells and endothelial cell dysfunction, resulting in the development of vascular diseases. In this review, we discuss the recent advances on the contribution of PVAT in CVDs. Specifically, we summarize the current proposed roles of PVAT in relationship with vascular contractility, endothelial dysfunction, neointimal formation, arterial stiffness, and aneurysm.

Computational Growth and Remodeling of Abdominal Aortic Aneurysms Constrained by the Spine

Abdominal aortic aneurysms (AAAs) evolve over time, and the vertebral column, which acts as an external barrier, affects their biomechanical properties. Mechanical interaction between AAAs and the spine is believed to alter the geometry, wall stress distribution, and blood flow, although the degree of this interaction may depend on AAAs specific configurations. In this study, we use a growth and remodeling (G&R) model, which is able to trace alterations of the geometry, thus allowing us to computationally investigate the effect of the spine for progression of the AAA. Medical image-based geometry of an aorta is constructed along with the spine surface, which is incorporated into the computational model as a cloud of points. The G&R simulation is initiated by local elastin degradation with different spatial distributions. The AAA-spine interaction is accounted for using a penalty method when the AAA surface meets the spine surface. The simulation results show that, while the radial growth of the AAA wall is prevented on the posterior side due to the spine acting as a constraint, the AAA expands faster on the anterior side, leading to higher curvature and asymmetry in the AAA configuration compared to the simulation excluding the spine. Accordingly, the AAA wall stress increases on the lateral, posterolateral, and the shoulder regions of the anterior side due to the AAA-spine contact. In addition, more collagen is deposited on the regions with a maximum diameter. We show that an image-based computational G&R model not only enhances the prediction of the geometry, wall stress, and strength distributions of AAAs but also provides a framework to account for the interactions between an enlarging AAA and the spine for a better rupture potential assessment and management of AAA patients.

Interaction of expanding abdominal aortic aneurysm with surrounding tissue: Retrospective CT image studies

OBJECTIVES

Abdominal aortic aneurysms (AAA) that rupture have a high mortality rate. Rupture occurs when local mechanical stress exceeds the local mechanical strength of an AAA, so stress profiles such as those from finite element analysis (FEA) are useful. The role and effect of surrounding tissues, like the vertebral column, which have not been extensively studied, are examined in this paper.

METHODS

Longitudinal CT scans from ten patients with AAAs were studied to see the effect of surrounding tissues on AAAs. Segmentation was performed to distinguish the AAA from other tissues and we studied how these surrounding tissues affected the shape and curvature of the AAA. Previously established methods by Veldenz et al. were used to split the AAA into 8 sections and examine the specific effects of surrounding tissues on these sections [1]. Three-dimensional models were created to better examine these effects over time. Registration was done in order to compare AAAs longitudinally.

RESULTS

The vertebral column and osteophytes were observed to have been affecting the shape and the curvature of the AAA. Interaction with the spine caused focal flattening in certain areas of the AAA. In 16 of the 41 CT scans, the right posterior dorsal section (section 5), had the highest radius of curvature, which was by far the section that had the maximum radius for a specified CT scan. Evolution of the growing AAA showed increased flattening in this section when comparing the last CT scan to the first scan.

CONCLUSION

Surrounding tissues have a clear influence on the geometry of an AAA, which may in turn affect the stress profile of AAA. Incorporating these structures in FEA and G&R models will provide a better estimate of stress.

CLINICAL RELEVANCE

Currently, size is the only variable considered when deciding whether to undergo elective surgery to repair AAA since it is an easy enough measure for clinicians to utilize. However, this may not be the best indicator of rupture risk because small aneurysms also contribute to a high mortality rate. AAA's wall stress is a superior indicator and may be better predicted with the inclusion of these surrounding tissues, which then could be used by clinicians in their decision-making process on whether to operate on an AAA.