1
|
Williamson PN, Docherty PD, Khanafer A, Steven BM. Analysis of Flow Through Extra-Anatomic Bypasses Between Supra-Aortic Branches Using Particle Image Velocimetry (PIV). CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2024; 18:11795468231221413. [PMID: 38449712 PMCID: PMC10916461 DOI: 10.1177/11795468231221413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/16/2023] [Indexed: 03/08/2024]
Abstract
Supra-aortic extra-anatomic debranch (SAD) are prosthetic surgical grafts used to revascularize head and neck arteries that would be blocked during a surgical or hybrid procedure used in treating ascending and arch of the aorta pathologies. However, bypassing the supra-aortic arteries but not occluding their orifice might introduce potential for competitive flow that reduces bypass patency. Competitive flow within the bypasses across the supra-aortic arteries has not previously been identified. This research identified haemodynamics due to prophylactic inclusion of bypasses from the brachiocephalic artery (BCA) to the left common carotid artery (LCCA), and from the LCCA to left subclavian artery (LSA). Four model configurations investigated the risk of competitive flow and the necessity of intentionally blocking the proximal LSA and/or LCCA. Particle image velocimetry (PIV) was used to assess haemodynamics in each model configuration. We found potential for competitive flow in the BCA-LCCA bypass when the LSA was blocked, in the LSA-LCCA bypass, when the LCCA alone or LCCA and LSA were blocked. Flow stagnated at the start of systole within the RCCA-LCCA bypass, along with notable recirculation zones and reciprocating flow occurring throughout systolic flow. Flow also stagnated in the LCCA-LSA bypass when the LCCA was blocked. There was a large recirculation in the LCCA-LSA bypass when both the LCCA and LSA were blocked. The presence of competitive flow in all other configurations indicated that it is necessary to block or ligate the native LCCA and LSA once the debranch is made and the thoracic endovascular aortic repair (TEVAR) completed.
Collapse
Affiliation(s)
- Petra N. Williamson
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Paul D. Docherty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
- Institute of Technical Medicine, Furtwangen University, Campus Villingen-Schwenningen, Villingen-Schwenningen, Germany
| | - Adib Khanafer
- Christchurch School of Medicine, University of Otago, Christchurch, New Zealand
| | - Briana M. Steven
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| |
Collapse
|
2
|
Rovas G, Bikia V, Stergiopulos N. Design and computational optimization of compliance-matching aortic grafts. Front Bioeng Biotechnol 2023; 11:1179174. [PMID: 37456727 PMCID: PMC10341153 DOI: 10.3389/fbioe.2023.1179174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction: Synthetic vascular grafts have been widely used in clinical practice for aortic replacement surgery. Despite their high rates of surgical success, they remain significantly less compliant than the native aorta, resulting in a phenomenon called compliance mismatch. This incompatibility of elastic properties may cause serious post-operative complications, including hypertension and myocardial hypertrophy. Methods: To mitigate the risk for these complications, we designed a multi-layer compliance-matching stent-graft, that we optimized computationally using finite element analysis, and subsequently evaluated in vitro. Results: We found that our compliance-matching grafts attained the distensibility of healthy human aortas, including those of young adults, thereby significantly exceeding the distensibility of gold-standard grafts. The compliant grafts maintained their properties in a wide range of conditions that are expected after the implantation. Furthermore, the computational model predicted the graft radius with enough accuracy to allow computational optimization to be performed effectively. Conclusion: Compliance-matching grafts may offer a valuable improvement over existing prostheses and they could potentially mitigate the risk for post-operative complications attributed to excessive graft stiffness.
Collapse
|
3
|
Zia AW, Liu R, Wu X. Structural design and mechanical performance of composite vascular grafts. Biodes Manuf 2022. [DOI: 10.1007/s42242-022-00201-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AbstractThis 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
Collapse
|
4
|
Williamson PN, Docherty PD, Yazdi SG, Khanafer A, Kabaliuk N, Jermy M, Geoghegan PH. Review of the Development of Hemodynamic Modeling Techniques to Capture Flow Behavior in Arteries Affected by Aneurysm, Atherosclerosis, and Stenting. J Biomech Eng 2022; 144:1128816. [PMID: 34802061 DOI: 10.1115/1.4053082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 02/05/2023]
Abstract
Cardiovascular diseases (CVDs) are the leading cause of death in the developed world. CVD can include atherosclerosis, aneurysm, dissection, or occlusion of the main arteries. Many CVDs are caused by unhealthy hemodynamics. Some CVDs can be treated with the implantation of stents and stent grafts. Investigations have been carried out to understand the effects of stents and stent grafts have on arteries and the hemodynamic changes post-treatment. Numerous studies on stent hemodynamics have been carried out using computational fluid dynamics (CFD) which has yielded significant insight into the effect of stent mesh design on near-wall blood flow and improving hemodynamics. Particle image velocimetry (PIV) has also been used to capture behavior of fluids that mimic physiological hemodynamics. However, PIV studies have largely been restricted to unstented models or intra-aneurysmal flow rather than peri or distal stent flow behaviors. PIV has been used both as a standalone measurement method and as a comparison to validate the CFD studies. This article reviews the successes and limitations of CFD and PIV-based modeling methods used to investigate the hemodynamic effects of stents. The review includes an overview of physiology and relevant mechanics of arteries as well as consideration of boundary conditions and the working fluids used to simulate blood for each modeling method along with the benefits and limitations introduced.
Collapse
Affiliation(s)
- Petra N Williamson
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand
| | - Paul D Docherty
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand
| | - Sina G Yazdi
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand
| | - Adib Khanafer
- Vascular, Endovascular, and Renal Transplant Unit, Christchurch Hospital, Canterbury District Health Board, Riccarton Avenue, Christchurch 8053, New Zealand; Christchurch School of Medicine, University of Otago, Dunedin 9016, New Zealand
| | - Natalia Kabaliuk
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand
| | - Mark Jermy
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand
| | - Patrick H Geoghegan
- School of Life and Health Sciences, Aston University, Birmingham B4 7ET, UK; Department of Mechanical and Industrial Engineering, University of South Africa, Johannesburg 2006, South Africa
| |
Collapse
|
5
|
Williamson PN, Docherty PD, Yazdi SG, Khanafer A, Kabaliuk N, Jermy M. PIV Analysis of Haemodynamics Distal to the Frozen Elephant Trunk Stent Surrogate. Cardiovasc Eng Technol 2021; 12:373-386. [PMID: 33675018 DOI: 10.1007/s13239-021-00521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The Frozen Elephant Trunk (FET) stent is a hybrid endovascular device that may be implemented in the event of an aneurysm or aortic dissection of the aortic arch or superior descending aorta. A Type 1B endoleak can lead to intrasaccular flow during systole and has been identified as a known failure of the FET stent graft. The purpose was to develop in-vitro modelling techniques to enable the investigation of the known failure. METHODS A silicone aortic phantom and 3D printed surrogate stent graft were manufactured to investigate the haemodynamics of a Type 1B endoleak. Physiological pulsatile flow dynamics distal to the surrogate stent graft were investigated in-vitro using Particle Image Velocimetry (PIV). RESULTS PIV captured recirculation zones and an endoleak distal to the surrogate stent graft. The endoleak was developed at the peak of systole and sustained until the onset of diastole. The endoleak was asymmetric, indicating a potential variation in the phantom artery wall thickness or stent alignment. Recirculation was identified on the posterior dorsal line during late systole. CONCLUSIONS The identification of the Type 1B endoleak proved that in-vitro modelling can be used to investigate complex compliance changes and wall motions. The recirculation may indicate the potential for long term intimal layer inflammatory issues such as atherosclerosis. These results may aid future remediation techniques or stent design. Further development of the methods used in this experiment may assist with the future testing of stents prior to animal or human trial.
Collapse
Affiliation(s)
- Petra N Williamson
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
| | - Paul D Docherty
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand. .,Institute of Technical Medicine, Furtwangen University, Campus Villingen-Schwenningen, Jakob-Kienzle Strasse 17, 78054, Villingen-Schwenningen, Germany.
| | - Sina G Yazdi
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
| | - Adib Khanafer
- Vascular, Endovascular & Renal Transplant Unit, Christchurch Hospital, Canterbury District Health Board, Riccarton Avenue, Christchurch, 8053, New Zealand.,Christchurch School of Medicine, University of Otago, Dunedin, New Zealand
| | - Natalia Kabaliuk
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
| | - Mark Jermy
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8041, New Zealand
| |
Collapse
|
6
|
Hemmler A, Lin A, Thierfelder N, Franz T, Gee MW, Bezuidenhout D. Customized stent-grafts for endovascular aneurysm repair with challenging necks: A numerical proof of concept. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2020; 36:e3316. [PMID: 32022404 DOI: 10.1002/cnm.3316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/05/2019] [Accepted: 01/23/2020] [Indexed: 06/10/2023]
Abstract
Endovascular aortic repair (EVAR) is a challenging intervention whose long-term success strongly depends on the appropriate stent-graft (SG) selection and sizing. Most off-the-shelf SGs are straight and cylindrical. Especially in challenging vessel morphologies, the morphology of off-the-shelf SGs is not able to meet the patient-specific demands. Advanced manufacturing technologies facilitate the development of highly customized SGs. Customized SGs that have the same morphology as the luminal vessel surface could considerably improve the quality of the EVAR outcome with reduced likelihoods of EVAR related complications such as endoleaks type I and SG migration. In this contribution, we use an in silico EVAR methodology that approximates the deployed state of the elastically deformable SG in a hyperelastic, anisotropic vessel. The in silico EVAR results of off-the-shelf SGs and customized SGs are compared qualitatively and quantitatively in terms of mechanical and geometrical parameters such as stent stresses, contact tractions, SG fixation forces and the SG-vessel attachment. In a numerical proof of concept, eight different vessel morphologies, such as a conical vessel, a barrel shaped vessel and a curved vessel, are used to demonstrate the added value of customized SGs compared to off-the-shelf SGs. The numerical investigation has shown large benefits of the highly customized SGs compared to off-the-shelf SGs with respect to a better SG-vessel attachment and a considerable increase in SG fixation forces of up to 50% which indicate decreased likelihoods of EVAR related complications. Hence, this numerical proof of concept motivates further research and development of highly customized SGs for the use in challenging vessel morphologies.
Collapse
Affiliation(s)
- André Hemmler
- Mechanics & High Performance Computing Group, Technische Universität München, Garching bei München, Germany
| | - Andrew Lin
- Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Observatory, South Africa
| | - Nikolaus Thierfelder
- Herzchirurgische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, München, Germany
| | - Thomas Franz
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, Observatory, South Africa
| | - Michael W Gee
- Mechanics & High Performance Computing Group, Technische Universität München, Garching bei München, Germany
| | - Deon Bezuidenhout
- Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Observatory, South Africa
| |
Collapse
|
7
|
Williamson P, Docherty PD, Yazdi SG, Jermy M, Khanafer A, Kabaliuk N, Geoghegan PH. PIV Analysis of Stented Haemodynamics in the Descending Aorta. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:4737-4740. [PMID: 31946920 DOI: 10.1109/embc.2019.8856823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiovascular diseases (CVD) are the leading cause of death in the developed world and aortic aneurysm is a key contributor. Aortic aneurysms typically occur in the thoracic aorta and can extend into the descending aorta. The Frozen Elephant Trunk stent (FET) is one of the leading treatments for the aneurysms extending into the descending aorta. This study focuses on the in-vitro experimentation of a stented descending aorta, investigating the haemodynamics in a compliant phantom. A silicone phantom of the descending aorta was manufactured using a lost core casting method. A PVC stent was manufactured using the same mould core. Particle Image Velocimetry (PIV) was used for pulsatile studies, focusing specifically on the passive fixation at the distal end of the FET. The results showed an apparent expansion in the diastolic period that was identified to be a collapse in the lateral plane. Flow recirculation regions were identified during the collapse. The collapse was attributed to low upstream and high downstream pressures causing a vacuum effect. The findings may imply a potential risk introduced by the FET stent that requires further investigation.
Collapse
|
8
|
Hemmler A, Lutz B, Reeps C, Gee MW. In silico study of vessel and stent-graft parameters on the potential success of endovascular aneurysm repair. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2019; 35:e3237. [PMID: 31315160 DOI: 10.1002/cnm.3237] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/29/2019] [Accepted: 07/10/2019] [Indexed: 06/10/2023]
Abstract
The variety of stent-graft (SG) design variables (eg, SG type and degree of SG oversizing) and the complexity of decision making whether a patient is suitable for endovascular aneurysm repair (EVAR) raise the need for the development of predictive tools to assist clinicians in the preinterventional planning phase. Recently, some in silico EVAR methods have been developed to predict the deployed SG configuration. However, only few studies investigated how to assess the in silico EVAR outcome with respect to EVAR complication likelihoods (eg, endoleaks and SG migration). Based on a large literature study, in this contribution, 20 mechanical and geometrical parameters (eg, SG drag force and SG fixation force) are defined to evaluate the quality of the in silico EVAR outcome. For a cohort of n = 146 realizations of parameterized vessel and SG geometries, the in silico EVAR results are studied with respect to these mechanical and geometrical parameters. All degrees of SG oversizing in the range between 5% and 40% are investigated continuously by a computationally efficient parameter continuation approach. The in silico investigations have shown that the mechanical and geometrical parameters are able to indicate candidates at high risk of postinterventional complications. Hence, this study provides the basis for the development of a simulation-based metric to assess the potential success of EVAR based on engineering parameters.
Collapse
Affiliation(s)
- André Hemmler
- Mechanics & High Performance Computing Group, Technische Universität München, Parkring 35, Garching b. München, 85748, Germany
| | - Brigitta Lutz
- Klinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstraße 74, Dresden, 01307, Germany
| | - Christian Reeps
- Klinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstraße 74, Dresden, 01307, Germany
| | - Michael W Gee
- Mechanics & High Performance Computing Group, Technische Universität München, Parkring 35, Garching b. München, 85748, Germany
| |
Collapse
|
9
|
Sharafuddin MJ, Reece TB, Papia G, Pozeg ZI, Peterson BG, Shafi B, Man J, Milner R. Proposed classification of endoleaks after endovascular treatment of Stanford type-B aortic dissections. Vascular 2019; 27:585-594. [PMID: 31067206 DOI: 10.1177/1708538119847394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Despite two decades of experience, no dedicated classification system exists to document and prognosticate patterns of endoleak encountered after endovascular therapy of type-B aortic dissection. This nomenclature gap has led to inconsistent management and underreporting of significant findings associated with adverse outcomes after endovascular treatment of type-B aortic dissection. Our goal was to propose a reproducible and prognostically relevant classification. Methods A multidisciplinary team of seven experienced open and endovascular aortic surgeons was assembled to provide consensus opinion. Extensive literature review was conducted. Deficiencies in the current classification approach of the various patterns of persistent filling of false lumen after endovascular therapy were identified. Results Our focus was to categorize high-risk and low-risk subgroups within endoleaks after endovascular treatment of type-B aortic dissection. In this classification, type-Ia endoleak refers to persistent filling of the false lumen in an antegrade manner. Causes include failure to cover the primary entry tear and sizing or technical related proximal seal failure. False lumen filling via distal entry tears is classified as type Ib endoleak, which is further sub-classified into b1 (major branch-related tears), and b2 (multiple small branches related tears). Retrograde ascending aortic dissection and stent graft-induced new entry were classified as type-I endoleaks (type-Ir and type-Is, respectively). Another focus was reclassification type-II endoleaks, with type-IIa endoleak referring to conventional retroleak from one or more posterior branches and type-IIx referring to retroleak from major branches (visceral or left subclavian arteries). Conclusions The majority of endoleaks after endovascular treatment of type-B aortic dissection are related to persistent or new filling of the false lumen. We propose a new false lumen-based classification schema for endoleaks occurring after endovascular therapy of type-B aortic dissection.
Collapse
Affiliation(s)
- Mel J Sharafuddin
- Department of Surgery, University of Iowa Hospitals and Clinics, USA
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, USA
| | - Giuseppe Papia
- Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Zlatko I Pozeg
- Department of Cardiothoracic Surgery, University of Manitoba School of Medicine, St. Boniface Hospital, Canada
| | - Brian G Peterson
- Department of Vascular Surgery, SSM Health St. Louis University Hospital, USA
| | - Bilal Shafi
- Department of Cardiothoracic Surgery, Sutter Health/Palo Alto Medical Foundation, USA
| | - Jeanette Man
- Department of Surgery, University of Iowa Hospitals & Clinics, USA
| | - Ross Milner
- University of Chicago Pritzker School of Medicine, USA
| |
Collapse
|
10
|
Hemodynamics and Wall Mechanics after Surgical Repair of Aortic Arch: Implication for Better Clinical Decisions. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9040807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Graft repair of aortic coarctation is commonly used to mimic the physiological aortic arch shape and function. Various graft materials and shapes have been adopted for the surgery. The goal of this work is to quantitatively assess the impact of graft materials and shapes in the hemodynamics and wall mechanics of the restored aortic arch and its correlation with clinical outcomes. A three-dimensional aortic arch model was reconstructed from magnetic resonance images. The fluid–structure interaction (FSI) analysis was performed to characterize the hemodynamics and solid wall mechanics of the repaired aortic arch. Two graft shapes (i.e., a half-moon shape and a crescent one) were considered. Material choices of the aortic arch repair included three commonly used graft materials (i.e., polytetrafluoroethylene (PTFE) synthetic graft, CorMatrix extracellular matrix, and pulmonary homograft) as well as one native tissue serving as a control. The pathological hemodynamic parameters, in terms of the percentage area of low wall shear stress (WSS), high oscillatory shear index (OSI), and high relative residence time (RRT), were quantified to be associated with potential clinical outcomes. Results have shown that the peak von Mises stress for the aortic arch repaired by the crescent graft was 76% less than that of the half-moon graft. Flow disturbance and recirculation were also minimized with the crescent graft. Moreover, pathological hemodynamic parameters were significantly reduced with the crescent graft. The graft material mismatch with the surrounding tissue aggregated the stress concentration on the aortic wall, but had minimal impact on flow dynamics. The present work demonstrated the role and importance of the graft geometry and materials on hemodynamics and wall mechanics, which could guide optimal graft decisions towards better clinical outcomes.
Collapse
|
11
|
The Modified Arch Landing Areas Nomenclature identifies hostile zones for endograft deployment: a confirmatory biomechanical study in patients treated by thoracic endovascular aortic repair†. Eur J Cardiothorac Surg 2018; 55:990-997. [DOI: 10.1093/ejcts/ezy409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/20/2022] Open
|