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Research Papers

Elevated Blood Viscosity and Microrecirculation Resulting From Coronary Stent Malapposition

[+] Author and Article Information
Eric K. W. Poon

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: epoon@unimelb.edu.au

Vikas Thondapu

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia;
Faculty of Medicine, Dentistry, and Health Sciences,
Department of Medicine,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: vthondapu@student.unimelb.edu

Umair Hayat

Faculty of Medicine, Dentistry and Health Sciences,
Department of Medicine,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: umair_hayat@hotmail.com

Peter Barlis

Department of Medicine,
Faculty of Medicine, Dentistry and Health Sciences,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: pbarlis@unimelb.edu.au

Chooi Yin Yap

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: c.yap3@student.unimelb.edu.au

Po-Hung Kuo

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: phkuo@student.unimelb.edu.au

Qisen Wang

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: qisenw@student.unimelb.edu.au

Jiawei Ma

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: Jiaweim@student.unimelb.edu.au

Shuang J. Zhu

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: sjzhu@unimelb.edu.au

Stephen Moore

IBM Research Australia,
Carlton 3053, Victoria, Australia
e-mail: stevemoore@au1.ibm.com

Andrew S. H. Ooi

Department of Mechanical Engineering,
Melbourne School of Engineering,
The University of Melbourne,
Melbourne 3010, Victoria, Australia
e-mail: a.ooi@unimelb.edu.au

1Corresponding author.

Manuscript received June 27, 2017; final manuscript received January 28, 2018; published online March 5, 2018. Assoc. Editor: Keefe B. Manning.

J Biomech Eng 140(5), 051006 (Mar 05, 2018) (9 pages) Paper No: BIO-17-1284; doi: 10.1115/1.4039306 History: Received June 27, 2017; Revised January 28, 2018

One particular complexity of coronary artery is the natural tapering of the vessel with proximal segments having larger caliber and distal tapering as the vessel get smaller. The natural tapering of a coronary artery often leads to proximal incomplete stent apposition (ISA). ISA alters coronary hemodynamics and creates pathological path to develop complications such as in-stent restenosis, and more worryingly, stent thrombosis (ST). By employing state-of-the-art computer-aided design software, generic stent hoops were virtually deployed in an idealized tapered coronary artery with decreasing malapposition distance. Pulsatile blood flow simulations were carried out using computational fluid dynamics (CFD) on these computer-aided design models. CFD results reveal unprecedented details in both spatial and temporal development of microrecirculation environments throughout the cardiac cycle (CC). Arterial tapering also introduces secondary microrecirculation. These primary and secondary microrecirculations provoke significant fluctuations in arterial wall shear stress (WSS). There has been a direct correlation with changes in WSS and the development of atherosclerosis. Further, the presence of these microrecirculations influence strongly on the local levels of blood viscosity in the vicinity of the malapposed stent struts. The observation of secondary microrecirculations and changes in blood rheology is believed to complement the wall (-based) shear stress, perhaps providing additional physical explanations for tissue accumulation near ISA detected from high resolution optical coherence tomography (OCT).

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Figures

Grahic Jump Location
Fig. 1

Present CFD solver demonstrates excellent agreements with both Poiseuille flow (Newtonian) and the analytical solution of Quemada type (non-Newtonian) fluid [14]

Grahic Jump Location
Fig. 2

Optical coherence tomography is used to image coronary arteries and stents. Individual stent struts appear as bright, high-intensity signals that cast a shadow radially outward. Cross-sectional optical coherence tomography (OCT) images demonstrate struts that are opposed distally (a, arrowheads) and malapposed proximally (b, arrowheads) in a naturally tapered artery. The bottom panel is a longitudinal view indicating the locations of the OCT images (a and b).

Grahic Jump Location
Fig. 3

(a) A representation of the hexahedral meshed computational domain of a generic MSH inside an idealized straight coronary artery. Pulsatile coronary blood flow is applied to the computational domain for CFD analyses; (b) showcases the rectangular surface elements on the stent hoop and the grid sketching on the lumen surface near the stent hoop; (c) demonstrates the increase in hexahedral element density near the lumen wall. Right panels show schematic diagrams of the three idealized cases: (d) case 1: a MSH with 90 μm square strut in a 3 mm diameter (D = 3 mm) straight coronary artery. Malapposition distance (MD, measured from the lumen wall to outer strut surface) is fixed at 150 μm. (e) Case 2: multiple MSHs in a straight coronary artery. A distance of L = 1.34 mm separates each stent hoop. (f) Case 3: multiple MSHs in a naturally tapered artery. The lumen diameter at the first stent hoop is set at 3 mm with a constant tapering angle of α = 1 deg. The natural tapering of the arterial wall also reduces MD from 150 μm proximally to ∼80 μm distally.

Grahic Jump Location
Fig. 4

Evolution of the longitudinal component of WSSx over a complete CC for a single MSH in a straight coronary artery (case 1). The donut chart represents (in proportion) three different phases of the CC: I, isovolumetric contraction; II, ejection; III, diastole. The corresponding coronary flow is shown in the inset of panels a–e.

Grahic Jump Location
Fig. 5

Evolution of 2D projected streamlines for a single MSH in a straight coronary artery (case 1) over a complete CC. Left and middle arrows in (a) and (b) indicate microrecirculation proximal and distal to the stent hoop, respectively, whereas left arrow at (e) shows microrecirculation distal to the stent hoop. Arrow on the far right identifies flow reattachment distal to microrecirculation.

Grahic Jump Location
Fig. 6

Comparison of micro-recirculations for cases 1, 2 and 3 at time instant A. (a) Case 1: presence of recirculation bubble both proximal (left arrow) and distal (right arrow) to the single MSH. (b) Case 2: flow is reversed near the lumen wall (identified by length of horizontal arrows). Microrecirculations are located inside the second to fourth MSH (vertical arrows). (c) Case 3: flow reversal on the lumen wall (horizontal arrows) and microrecirculation located inside the second to fourth stent hoop. Additional microrecirculation (vertical arrows) can be observed in between the primary microrecirculation distal to the second MSH. Velocity contour levels are same in Fig. 5.

Grahic Jump Location
Fig. 7

Contours of local elevation in blood viscosity, μ/μ, at time instant A for (a) case 2 and (b) case 3. Circles point to localized regions of high viscosity.

Grahic Jump Location
Fig. 8

Two-dimensional histograms showing volume percentage of elevated viscosity (μ/μ) in the longitudinal direction. The region of interest is 0.4 mm proximal and distal to the MSH with the longitudinal centroid of the MSH located at zero position. Case 1: straight artery, single MSH; case 2: straight artery, multiple MSHs; case 3: tapered artery, multiple stent hoops. For cases 2 and 3 with multiple MSHs, the position of each MSH is indicated on the top left corner.

Grahic Jump Location
Fig. 9

Optical coherence tomography (OCT) shows the presence of reactive tissue (inner arrows) formed over malapposed struts (outer arrows)

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