Blocked-flow vs. free-flow cyanoacrylate glue embolization: Histological differences in an in vivo rabbit renal artery model

PURPOSE

The purpose of this in vivo animal study was to compare the acute histological effects on the arterial vessel wall of free-flow vs. blocked-flow embolization with metacryloxysulfolane-n‑butyl cyanoacrylate (MS-NBCA) in several concentrations.

MATERIALS AND METHODS

A total of 42 rabbit renal arteries were embolized using MS-NBCA mixed with ethiodized oil. The MS-NBCA concentration was 12.5%, 25%, or 50%. All mixtures were injected under both free-flow and blocked-flow conditions. The rabbits were euthanised 30 min after arterial embolization. Arterial-lumen distension, intimal inflammation and necrosis, peri‑arterial edema, and distality of MS-NBCA penetration were assessed histologically. Multivariable regression analyses were performed using a manual backward procedure, with linear, ordinal and logistic regression to search for factors associated with these outcomes RESULTS: Marked or severe dilatation was observed in 36 out of 42 arteries (86%) and marked or transmural intimal arteritis in all 42 arteries (42/42; 100%). Lumen dilatation caused focal vessel-wall flattening, which resulted in intimal necrosis. Multifocal necrosis extending from the intima to the media occurred in 23 out of 42 kidneys (55%) and peri‑arterial edema with multifocal vascular leakage in 19 out of 42 kidneys (45%). At multivariable analysis, blocked-flow MS-NBCA injection was associated with greater severity of vessel-wall lesions, including intimal arteritis (P = 0.003) and intimal necrosis (P = 0.014), compared to free-flow injection. Blocked-flow injection was also associated with peri‑arterial edema (P = 0.008) and greater distality of MS-NBCA penetration (P = 0.001).

CONCLUSION

Blocked-flow MS-NBCA injection during renal artery embolization is significantly associated with more acute arterial-wall damage and greater distality of glue penetration compared to free-flow injection in a rabbit model. These preliminary findings may have clinical implications, as blocked-flow injection is routinely used to treat specific vascular diseases or malformations in human.

Iodixanol as a New Contrast Agent for Cyanoacrylate Embolization: A Preliminary In Vivo Swine Study

N-butyl cyanoacrylate (NBCA) is a lipophilic, permanent embolic glue that must be opacified for fluoroscopic guidance. Empirically, lipophilic Lipiodol Ultra Fluid® (LUF) has been added to produce a single-phase physically stable mixture. Varying the dilution ratio allows control of glue polymerization kinetics. LUF is far more costly than water-soluble iodinated contrast agents (ICAs). Our purpose was to evaluate whether a water-soluble nonionic iso-osmolar ICA could be used instead. We embolized both renal arteries of six swine using 1:3 NBCA-LUF or NBCA-iodixanol in 1:1, 1:3, and 1:7 ratios. We used both micro-computed tomography to assess the distality of glue penetration and indexed cast ratio and histology to assess distality, arterial obliteration, vessel-wall damage, and renal-parenchyma necrosis. Glue-LUF produced significantly greater indexed cast ratio and renal-artery ROI values and a significantly shorter cast-to-capsule distance. The injected volume was significantly greater with 1:7 iodixanol than with the other mixtures. No significant differences were found for histological evidence of artery obliteration, vessel-wall damage, or renal-parenchyma necrosis. This is the first study dealing with ICA alone as a contrast agent for cyanoacrylate embolization, compared to LUF. More research is needed to determine whether water-soluble nonionic iodinated agents can be used for human NBCA embolization given the good safety profile, availability, and low cost of ICA.

Data-driven kinematics-consistent model order reduction of fluid-structure interaction problems: application to deformable microcapsules in a Stokes flow

In this paper, we present a generic approach of a dynamical data-driven model order reduction technique for three-dimensional fluid-structure interaction problems. A low-order continuous linear differential system is identified from snapshot solutions of a high-fidelity solver. The reduced order model (ROM) uses different ingredients like proper orthogonal decomposition (POD), dynamic mode decomposition (DMD) and Tikhonov-based robust identification techniques. An interpolation method is used to predict the capsule dynamics for any value of the governing non-dimensional parameters that are not in the training database. Then a dynamical system is built from the predicted solution. Numerical evidence shows the ability of the reduced model to predict the time-evolution of the capsule deformation from its initial state, whatever the parameter values. Accuracy and stability properties of the resulting low-order dynamical system are analysed numerically. The numerical experiments show a very good agreement, measured in terms of modified Hausdorff distance between capsule solutions of the full-order and low-order models both in the case of confined and unconfined flows. This work is a first milestone to move towards real time simulation of fluid-structure problems, which can be extended to non-linear low-order systems to account for strong material and flow non-linearities. It is a valuable innovation tool for rapid design and for the development of innovative devices.

X-ray Microtomography to Assess Determinants of In Vivo N-Butyl Cyanoacrylate Glubran®2 Polymerization: A Rabbit-Model Study

Although introduced decades ago, few cyanoacrylate glues have been approved for endovascular use, despite evidence of their usefulness, notably for complex procedures suchas hemostatic embolization. Indications include massive bleeding requiring emergent hemostasis and prevention of severe bleeding during scheduled surgery to remove a hypervascular tumor. Adding radiopaque Lipiodol Ultra Fluid® (LUF) modulates glue polymerization and allows fluoroscopic guidance, but few comparative in vivo studies have assessed the impact of the resulting change in glue concentration or of other factors such as target-vessel blood flow. In a rabbit model, we used ex vivo X-ray microtomography to assess the results of in vivo renal-artery embolization by various mixtures of N-butyl cyanoacrylate (NBCA), metacryloxysulfolane, and LUF. Overall, penetration to the superficial interlobular arteries was achieved in about two-thirds of cases and into the capillaries in nearly half the cases, while cast fragmentation was seen in slightly more than half the cases. Greater NBCA dilution and the blocked-blood-flow technique were independently associated with greater distality of penetration. Blocked-blood-flow injection was independently associated with absence of fragmentation, capillary penetration, a shorter cast-to-capsule distance, and higher cast attenuation. A larger mixture volume was independently associated with higher indexed cast ratio and deeper penetration. Finally, microtomography is an adapted tool to assess ex vivo distribution of glue cast.

In Vivo Experimental Endovascular Uses of Cyanoacrylate in Non-Modified Arteries: A Systematic Review

Cyanoacrylates were first used for medical purposes during World War II to close skin wounds. Over time, medical applications were developed, specifically in the vascular field. Uses now range from extravascular instillation in vascular grafting to intravascular injection for embolization. These applications were made possible by the conduct of numerous preclinical studies involving a variety of tests and outcome measures, including angiographic and histological criteria. Cyanoacrylates were first harshly criticized by vascular surgeons, chiefly due to their fast and irreversible polymerization. Over the past five years, however, cyanoacrylates have earned an established place in endovascular interventional radiology. Given the irreversible effects of cyanoacrylates, studies in animal models are ethically acceptable only if supported by reliable preliminary data. Many animal studies of cyanoacrylates involved the experimental creation of aneurysms or arteriovenous fistulas, whose treatment by endovascular embolization was then assessed. In clinical practice, however, injection into non-modified arteries may be desirable, for instance, to deprive a tumor of its vascular supply. To help investigators in this field select the animal models and procedures that are most appropriate for their objectives, we have reviewed all published in vivo animal studies that involved the injection of cyanoacrylates into non-modified arteries to discuss their main characteristics and endpoints.

Modelling of damage of a liquid-core microcapsule in simple shear flow until rupture

Capsules, composed of a liquid core protected by a thin deformable membrane, offer high-potential applications in many fields of industry such as bioengineering. One of their limitations comes from the absence of models of capsule damage and/or rupture when they are subjected to an external flow. To assess when rupture is initiated, we develop a fluid-structure interaction (FSI) numerical model of a capsule in Stokes flow that accounts for potential damage of the capsule membrane. We consider the framework of Continuum Damage Mechanics and model the membrane with an isotropic brittle damage model, in which the membrane damage state depends on the history of loading. The FSI problem is solved by coupling the finite element method, to solve for the membrane deformation, with the boundary integral method, to solve for the inner and outer fluid flows. The model is applied to an initially spherical capsule subjected to a simple shear flow. Damage initiates at a critical value of the capillary number, ratio of the fluid viscous forces to the membrane elastic forces, and rupture at a higher capillary number, when it reaches a threshold value. The material parameters introduced in the damage model do not influence the mode of damage but only the values of the critical and threshold capillary numbers. When the capillary number is larger than the critical value, damage develops in the two symmetric central regions containing the vorticity axis. It is indeed in these regions that the internal tensions are the highest on the membrane.

Sorting of capsules according to their stiffness: from principle to application

We assess experimentally the ability of a simple flow-based sorting device, recently proposed numerically by [Zhu et al., Soft Matter, 2014, 10, 7705-7711], to separate capsules according to their stiffness. The device consists of a single pillar with a half-cylinder cross-section which partially obstructs a flow channel so that initially centred, propagating capsules deform and circumvent the obstacle into an expanding channel (or diffuser). We perform experiments with millimetric capsules of fixed size which indicate that the deviation of the capsule in the diffuser varies monotonically with a capillary number - the ratio of viscous to elastic stresses - where the elastic stresses are measured independently to include the effects of pre-inflation, membrane thickness and material properties. We find that soft capsules with resistance to deformation differing by a factor of 1.5 can be reliably separated in the diffuser but that experimental variability increases significantly with capsule stiffness. We extend the study to populations of microcapsules with size polydispersity. We find that the combined effects of increasing capsule deformability and relative constriction of the device with increasing capsule size enable the tuning of the imposed flow so that capsules can be separated based on their shear modulus but irrespectively of their size.

Quantitative assessment of the flow distribution in the branches of the external carotid by non-injected flow MRI

Owing to the lack of databases of blood flow distributions in the external carotid branches, surgeons currently rely on per-operative imaging and on their experience to choose the recipient vessels for microsurgical facial reconstructions. But, thanks to three-dimensional phase contrast angiography (PCA) and kinematic CINE phase contrast (PC) sequences, MRI technologies have the potential to provide quantitative anatomical and hemodynamic information without injection of contrast agent. Having developed and optimized PC-MRI sequences for the small facial vessels, our objective was to investigate the haemodynamic and blood flow distribution in the external carotid branches. We included 31 healthy volunteers in an MRI prospective study. Two-dimensional CINE PC-MRI sequences (average duration time of 2 min 40 s ± 24 s) were performed in the external carotid collaterals (n = 290). A statistical analysis of the flow measurements showed that, despite large interpersonal variabilities, a general flow distribution pattern was obtained by dividing the vessel flow rates by the external carotid artery one (providing local percentages of the incoming flow). The vessels could then be classified in three haemodynamic groups (p < 0.05 Student's test): "low flow" group (lingual artery-12.5 ± 5% of incoming flow), "intermediate flow" group (superior thyroid artery-16.5 ± 10%, internal maxillary artery-20.5 ± 11%, superficial temporal artery-18.4 ± 6%), "high flow" group (facial artery -26.6 ± 10%). Thanks to this general flow distribution mapping, it is now possible to estimate the flow rates in the distal branches of any individual from a single blood flow measurement in the external carotid artery.

Influence of principal component analysis acceleration factor on velocity measurement in 2D and 4D PC-MRI

OBJECTIVE

The objective of the study was to determine how to optimize 2D and 4D phase-contrast magnetic resonance imaging (PC-MRI) acquisitions to acquire flow velocities in millimetric vessels. In particular, we search for the best compromise between acquisition time and accuracy and assess the influence of the principal component analysis (PCA).

MATERIALS AND METHODS

2D and 4D PC-MRI measurements are conducted within two in vitro vessel phantoms: a Y-bifurcation phantom, the branches of which range from 2 to 5 mm in diameter, and a physiological subject-specific phantom of the carotid bifurcation. The same sequences are applied in vivo in carotid vasculature.

RESULTS

For a vessel oriented in the axial direction, both 2D and axial 4D PC-MRI provided accuracy measurements regardless of the k-t PCA factor, while the acquisition time is reduced by a factor 6 for k-t PCA maximum value. The in vivo measurements show that the proposed sequences are adequate to acquire 2D and 4D velocity fields in millimetric vessels and with clinically realistic time durations.

CONCLUSION

The study shows the feasibility of conducting fast, high-resolution PC-MRI flow measurements in millimetric vessels and that it is worth maximizing the k-t PCA factor to reduce the acquisition time in the case of 2D and 4D axial acquisitions.

Squeezing bio-capsules into a constriction: deformation till break-up

We study experimentally the deformation and break-up of liquid-filled capsules trapped at an axisymmetric step constriction, and subjected to increasing pressure drops. We considered biological (trout fish eggs) and bioartificial (made of ovalbumin and alginate) ones, with the objective to characterize the transition to break-up. We find that both capsule populations behave as a brittle material. They do not exhibit any plastic deformation prior to break-up. Moreover critical pressure drop exhibits a stochastic behavior as known for the fracture of disordered media. The break-up probability follows a three-parameter Weibull distribution, from which one can deduce the capsule rupture characteristics.

Numerical simulation of the fluid structure interactions in a compliant patient-specific arteriovenous fistula

The objective of the study is to investigate numerically the fluid-structure interactions (FSI) in a patient-specific arteriovenous fistula (AVF) and analyze the degree of complexity that such a numerical simulation requires to provide clinically relevant information. The reference FSI simulation takes into account the non-Newtonian behavior of blood, as well as the variation in mechanical properties of the vascular walls along the AVF. We have explored whether less comprehensive versions of the simulation could still provide relevant results. The non-Newtonian blood model is necessary to predict the hemodynamics in the AVF because of the predominance of low shear rates in the vein. An uncoupled fluid simulation provides informative qualitative maps of the hemodynamic conditions in the AVF; quantitatively, the hemodynamic parameters are accurate within 20% maximum. Conversely, an uncoupled structural simulation with non-uniform wall properties along the vasculature provides the accurate distribution of internal wall stresses, but only at one instant of time within the cardiac cycle. The FSI simulation advantageously provides the time-evolution of both the hemodynamic and structural stresses. However, the higher computational cost renders a clinical use still difficult in routine.

Impact of alginate composition: from bead mechanical properties to encapsulated HepG2/C3A cell activities for in vivo implantation

Recently, interest has focused on hepatocytes' implantation to provide end stage liver failure patients with a temporary support until spontaneous recovery or a suitable donor becomes available. To avoid cell damage and use of an immunosuppressive treatment, hepatic cells could be implanted after encapsulation in a porous biomaterial of bead or capsule shape. The aim of this study was to compare the production and the physical properties of the beads, together with some hepatic cell functions, resulting from the use of different material combinations for cell microencapsulation: alginate alone or combined with type I collagen with or without poly-L-lysine and alginate coatings. Collagen and poly-L-lysine increased the bead mechanical resistance but lowered the mass transfer kinetics of vitamin B12. Proliferation of encapsulated HepG2/C3A cells was shown to be improved in alginate-collagen beads. Finally, when the beads were subcutaneously implanted in mice, the inflammatory response was reduced in the case of alginate mixed with collagen. This in vitro and in vivo study clearly outlines, based on a systematic comparison, the necessity of compromising between material physical properties (mechanical stability and porosity) and cell behavior (viability, proliferation, functionalities) to define optima hepatic cell microencapsulation conditions before implantation.

Can sonication enhance release from liquid-core capsules with a hydrogel membrane?

The objective is to investigate the influence of sonication on the mechanical and release properties of hydrogel capsules. A new fabrication process is developed to fabricate millimetric capsules made of a highly-viscous liquid core protected by a thin hyperelastic alginate membrane. At high intensities and/or long exposure times, sonication can lead to the capsule rupture, because it induces fatigue in the membrane. Below the breakup threshold, no remnant effect of sonication is, however, measured on the capsule mechanical properties. The release is studied by sonicating capsules filled with blue dextran suspended in an aqueous solution. The mass release that results from sonication is found to be proportional to the sonication duration time and pressure wave amplitude. A possible physical interpretation is that the acoustic streaming flow induced by the ultrasonic wave enhances convection in the vicinity of the capsule membrane and thus mass release. We have finally quantified the passive release subsequent to low-intensity sonications: it is on average identical to the one measured on non-sonicated capsules. Overall the membrane therefore recovers its physical and mechanical properties after sonication. If sonication leads to an increase in porosity of the capsule membrane, the increase is temporary and reverses back at the end of the ultrasonic stimulation.

Hemodynamic changes occurring during the progressive enlargement of abdominal aortic aneurysms

The purpose of this study is to characterize the evolution of the hemodynamic forces acting on the arterial walls at progressive stages of enlargement of abdominal aortic aneurysms (AAA). The specific aims are twofold: first, to determine the magnitude of the "wall shear stresses" (WSS) and their spatial and temporal gradients at various stages of enlargement, and second, to identify the critical size at which the formation of regions of stasis and/or the transition to a turbulent state occur inside the AAA. A parametric in vitro study of the pulsatile blood flow was conducted in rigid models of AAA by systematically varying the hemodynamic conditions and the size of the aneurysm. The instantaneous flow characteristics inside the AAA models were measured along the cardiac cycle, using tomographic digital particle image velocimetry (TDPIV). The TDPIV measurements showed that even for the case of large dilatation ratios (internal diameter >4.5 mm), the flow inside the AAA remained fully attached to the walls during systole, but massively detached during diastole. A critical aneurysm aspect ratio (length-to-diameter ratio) was found, for which a transition to a turbulent state occurred. The formation of internal shear layers (internal jet) and slowly recirculating regions (stasis) generated large spatial gradients of WSS and regions of low and oscillating WSS. The formation of regions of flow stasis was observed even at very early stages in the aneurysm enlargement. These spatial and temporal variations in the hemodynamic forces, the formation of regions of stasis, and the transition to turbulence are postulated to play an important role in the etiology of the disease by activating endoluminar thrombus formation, lipid deposition, and certain inflammatory mechanisms.