Trends in Cerebrovascular Surgery and Interventions

This is an open access proceeding book of 9th European-Japanese Cerebrovascular Congress at Milan 2018. Since many experts from Europe and Japan had very important and fruitful discussion on the management of Cerebrovascular diseases, the proceeding book is very attractive for the physician and scientists of the area

Simulation numérique des interactions fluide-structure dans une fistule artério-veineuse sténosée et des effets de traitements endovasculaires

Une fistule artérioveineuse (FAV) est un accès vasculaire permanent créé par voie chirurgicale en connectant une veine et une artère chez le patient en hémodialyse. Cet accès vasculaire permet de mettre en place une circulation extracorporelle partielle afin de remplacer les fonctions exocrines des reins. En France, environ 36000 patients sont atteint d insuffisance rénale chronique en phase terminale, stade de la maladie le plus grave qui nécessite la mise en place d un traitement de suppléance des reins : l hémodialyse. La création et présence de la FAV modifient significativement l hémodynamique dans les vaisseaux sanguins, au niveau local et systémique ainsi qu à court et à plus long terme. Ces modifications de l hémodynamiques peuvent induire différents pathologies vasculaires, comme la formation d anévrysmes et de sténoses. L objectif de cette étude est de mieux comprendre le comportement mécanique et l hémodynamique dans les vaisseaux de la FAV. Nous avons étudié numériquement les interactions fluide-structure (IFS) au sein d une FAV patient-spécifique, dont la géométrie a été reconstruite à partir d images médicales acquises lors d un précédent doctorat. Cette FAV a été créée chez le patient en connectant la veine céphalique du patient à l artère radiale et présente une sténose artérielle réduisant de 80% la lumière du vaisseau. Nous avons imposé le profil de vitesse mesuré sur le patient comme conditions aux limites en entrée et un modèle de Windkessel au niveau des sorties artérielle et veineuse. Nous avons considéré des propriétés mécaniques différentes pour l artère et la veine et pris en compte le comportement non-Newtonien du sang. Les simulations IFS permettent de calculer l évolution temporelle des contraintes hémodynamiques et des contraintes internes à la paroi des vaisseaux. Nous nous sommes demandées aussi si des simulations non couplées des équations fluides et solides permettaient d obtenir des résultats suffisamment précis tout en réduisant significativement le temps de calcul, afin d envisager son utilisation par les chirurgiens. Dans la deuxième partie de l étude, nous nous sommes intéressés à l effet de la présence d une sténose artérielle sur l hémodynamique et en particulier à ses traitements endovasculaires. Nous avons dans un premier temps simulé numériquement le traitement de la sténose par angioplastie. En clinique, les sténoses résiduelles après angioplastie sont considérées comme acceptables si elles obstruent moins de 30% de la lumière du vaisseau. Nous avons donc gonflé le ballonnet pour angioplastie avec différentes pressions de manière à obtenir des degrés de sténoses résiduelles compris entre 0 et 30%. Une autre possibilité pour traiter la sténose est de placer un stent après l angioplastie. Nous avons donc dans un deuxième temps simulé ce traitement numériquement et résolu le problème d IFS dans la fistule après la pose du stent. Dans ces simulations, la présence du stent a été prise en compte en imposant les propriétés mécaniques équivalentes du vaisseau après la pose du stent à une portion de l artère. Dans la dernière partie de l étude nous avons mis en place un dispositif de mesure par PIV (Particle Image Velocimetry). Un moule rigide et transparent de la géométrie a été obtenu par prototypage rapide. Les résultats expérimentaux ont été validés par comparaison avec les résultats des simulations numériques.An arteriovenous fistula (AVF) is a permanent vascular access created surgically connecting a vein onto an artery. It enables to circulate blood extra-corporeally in order to clean it from metabolic waste products and excess of water for patients with end-stage renal disease undergoing hemodialysis. The hemodynamics results to be significantly altered within the arteriovenous fistula compared to the physiological situation. Several studies have been carried out in order to better understand the consequences of AVF creation, maturation and frequent use, but many clinical questions still lie unanswered. The aim of the present study is to better understand the hemodynamics within the AVF, when the compliance of the vascularwall is taken into account. We also propose to quantify the effect of a stenosis at the afferent artery, the incidence of which has been underestimated for many years. The fluid-structure interactions (FSI) within a patient-specific radio-cephalic arteriovenous fistula are investigated numerically. The considered AVF presents an 80% stenosis at the afferent artery. The patient-specific velocity profile is imposed at the boundary inlet, and a Windkessel model is set at the arterial and venous outlets. The mechanical properties of the vein and the artery are differentiated. The non-Newtonian blood behavior has been taken into account. The FSI simulation advantageously provides the time-evolution of both the hemodynamic and structural stresses, and guarantees the equilibrium of the solution at the interface between the fluid and solid domains. The FSI results show the presence of large zones of blood flow recirculation within the cephalic vein, which might promote neointima formation. Large internal stresses are also observed at the venous wall, which may lead to wall remodeling. The fully-coupled FSI simulation results to be costly in computational time, which can so far limit its clinical use. We have investigated whether uncoupled fluid and structure simulations can provide accurate results and significantly reduce the computational time. The uncoupled simulations have the advantage to run 5 times faster than the fully-coupled FSI. We show that an uncoupled fluid simulation provides informative qualitative maps of the hemodynamic conditions in the AVF. Quantitatively, the maximum error on the hemodynamic parameters is 20%. The 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. Although partially inaccurate or incomplete, the results of the uncoupled simulations could still be informative enough to guide clinicians in their decision-making. In the second part of the study we have investigated the effects of the arterial stenosis on the hemodynamics, and simulated its treatment by balloon-angioplasty. Clinically, balloon-angioplasty rarely corrects the stenosis fully and a degree of stenosis remains after treatment. Residual degrees of stenosis below 30% are considered as successful. We have inflated the balloon with different pressures to simulate residual stenoses ranging from 0 to 30%. The arterial stenosis has little impact on the blood flow distribution: the venous flow rate remains unchanged before and after the treatment and thus permits hemodialysis. But an increase in the pressure difference across the stenosis is observed, which could cause the heart work load to increase. To guarantee a pressure drop below 5 mmHg, which is considered as the threshold stenosis pressure difference clinically, we find that the residual stenosis degree must be 20% maximum.COMPIEGNE-BU (601592101) / SudocSudocFranceF

The Haemodynamics of a Stented Arteriovenous Fistula through Experiments and Flow Modelling

The arteriovenous fistula (AVF) is a vasculature created for end-stage renal disease patients who undergo haemodialysis. This vasculature is often affected by stenosis in the juxta-anastomotic (JXA) region and the presence of disturbed haemodynamics within the vessel is known to initiate such diseased conditions. A novel treatment involving the implantation of a flexible stent in the JXA region has shown potential for retaining healthy AVFs. Only a limited number of experimental studies have been conducted to understand the disturbed flow conditions, while the impact of stent implantation on the haemodynamics within the AVF is yet to be explored. The study was initiated by developing a benchtop patient-specific AVF model to conduct a Tomographic Particle Image Velocimetry (Tomo-PIV) measurement. The subsequent temporally resolved volumetric velocity field was phase-averaged to quantify fluctuations occurring over the inlet pulsatile conditions. It was noted that high turbulent kinetic energy (TKE) was generated at the JXA region. To study the effects of the stent implantation, Large Eddy Simulations (LES) comparing the AVF geometry with and without the presence of the stent implantation were conducted. The trajectory of the flow in the stented case was funnelled within the stent encapsulated region which in turn, contained the disturbed flow within the stent lumen while mitigating the generation of turbulence. Consequently, the distribution of adverse wall shear stress (WSS) in the stented region was much lower compared to that of the `stent-absent' case. Simulations were also conducted on the diseased patient AVF, before the stent implantation, to make an overall assessment of the effect of treatment. Larger and persistent regions of high TKE were noted in the vessel downstream of the stenosis despite the lower velocity of flow in the diseased model. In summary, the stent implantation in the patient AVF showed the ability to funnel flow disturbances away from the vessel wall, thereby leading to lower adverse WSS distributions. The presence of the stent also mitigated turbulence generation. These findings provide valuable insight into the favourable haemodynamic effects of this novel endovascular procedure, thus, substantiating this treatment strategy to treat vascular disease in AVFs

Patient-Specific Computational Modeling of Upper Extremity Arteriovenous Fistula Creation: Its Feasibility to Support Clinical Decision-Making

<div><h3>Introduction</h3><p>Inadequate flow enhancement on the one hand, and excessive flow enhancement on the other hand, remain frequent complications of arteriovenous fistula (AVF) creation, and hamper hemodialysis therapy in patients with end-stage renal disease. In an effort to reduce these, a patient-specific computational model, capable of predicting postoperative flow, has been developed. The purpose of this study was to determine the accuracy of the patient-specific model and to investigate its feasibility to support decision-making in AVF surgery.</p> <h3>Methods</h3><p>Patient-specific pulse wave propagation models were created for 25 patients awaiting AVF creation. Model input parameters were obtained from clinical measurements and literature. For every patient, a radiocephalic AVF, a brachiocephalic AVF, and a brachiobasilic AVF configuration were simulated and analyzed for their postoperative flow. The most distal configuration with a predicted flow between 400 and 1500 ml/min was considered the preferred location for AVF surgery. The suggestion of the model was compared to the choice of an experienced vascular surgeon. Furthermore, predicted flows were compared to measured postoperative flows.</p> <h3>Results</h3><p>Taken into account the confidence interval (25^th and 75^th percentile interval), overlap between predicted and measured postoperative flows was observed in 70% of the patients. Differentiation between upper and lower arm configuration was similar in 76% of the patients, whereas discrimination between two upper arm AVF configurations was more difficult. In 3 patients the surgeon created an upper arm AVF, while model based predictions allowed for lower arm AVF creation, thereby preserving proximal vessels. In one patient early thrombosis in a radiocephalic AVF was observed which might have been indicated by the low predicted postoperative flow.</p> <h3>Conclusions</h3><p>Postoperative flow can be predicted relatively accurately for multiple AVF configurations by using computational modeling. This model may therefore be considered a valuable additional tool in the preoperative work-up of patients awaiting AVF creation.</p> </div

Relationship between the morphology of A-1 segment of anterior cerebral artery and anterior communicating artery aneurysms

Background: The anterior communicating artery (ACoA) is one of the most frequent sites for cerebral aneurysm. The peculiar directions of projection of aneurysms offer great challenges to clinical treatment. Objetives: To establish the relationship between morphology of A-1 segment of anterior cerebral artery (ACA) and aneurismal projection. Methods: Randomly selected digital subtraction angiography data of 264 anterior communicating artery aneurysms (ACoAA) cases and 296 cases of other cerebral vascular diseases in the same period were retrospectively analyzed. Results: Among 264 ACoAA patients, the morphology of A-1 segment showed type Ⅰa in 158 sides, type Ⅰb in 11, type Ⅱa in 35, type Ⅱb in 87, type Ⅲ in 171 and absence in 66. The morphology of A-1 segment in 296 patients with other cerebral vascular diseases displayed type Ⅰa in 195 sides, type Ⅰb in 20, type Ⅱa in 47, type Ⅱ b in 74, type Ⅲ in 217 and absence in 39. The non-visualization of A-1 segment in the group of ACoAA occurred more than in the control group (χ2=11.482, p=0.001). The classifications of ACoAAs in 264 patients were confirmed as anterior-superior type in 121 cases, anterior-inferior type in 105, complicated type in 16, posterior-inferior type in 12 and posterior-superior type in 10. The correlation between morphology of A-1 segment of ACA and classifications of ACoAA was significant (p=0.000; C=0.619, p=0.000). The direction of ACoAA was downward when the A-1 segment of ACA was Type Ⅰa or Type Ⅱa, and was upward when it was Type Ⅰb or Type Ⅱb，and was upward or downward or complicated when it was Type Ⅲ. Conclusion: The relationship between morphology of A-1 segment of ACA and classification of ACoAA is clarified in the present study, which is helpful to surgical treatment.Keywords: anterior cerebral artery; morphology of A-1 segment; projection of anterior communicating artery aneurysmAfrican Health sciences Vol 14 No. 1 March 201

Morphological and hemodynamical alterations in brachial artery and cephalic vein. An image‐based study for preoperative assessment for vascular access creation

The current study aims to computationally evaluate the effect of right upper arm position on the geometric and hemodynamic characteristics of the brachial artery (BA) and cephalic vein (CV) and, furthermore, to present in detail the methodology to characterise morphological and hemodynamical healthy vessels. Ten healthy volunteers were analysed in two configurations, the supine (S) and the prone (P) position. Lumen 3D surface models were constructed from images acquired from a non-contrast MRI sequence. Then, the models were used to numerically compute the physiological range of geometric (n = 10) and hemodynamic (n = 3) parameters in the BA and CV. Geometric parameters such as curvature and tortuosity, and hemodynamic parameters based on wall shear stress (WSS) metrics were calculated with the use of computational fluid dynamics. Our results highlight that changes in arm position had a greater impact on WSS metrics of the BA by altering the mean and maximum blood flow rate of the vessel. Whereas, curvature and tortuosity were found not to be significantly different between positions. Inter-variability was associated with antegrade and retrograde flow in BA, and antegrade flow in CV. Shear stress was low and oscillatory shear forces were negligible. This data suggests that deviations from this state may contribute to the risk of accelerated intimal hyperplasia of the vein in arteriovenous fistulas. Therefore, preoperative conditions coupled with post-operative longitudinal data will aid the identification of such relationships

Customization of Aneurysm Scaffold Geometries for In Vitro Tissue-Engineered Blood Vessel Mimics to Use as Models for Neurovascular Device Testing

Cerebral aneurysms occur due to the ballooning of blood vessels in the brain. Rupture of aneurysms can cause a subarachnoid hemorrhage, which, if not fatal, can cause permanent neurologic deficits. Minimally invasive neurovascular devices, such as embolization coils and flow diverters, are methods of treatment utilized to prevent aneurysm rupture. The rapidly growing market for neurovascular devices necessitates the development of accurate aneurysm models for preclinical testing. In vivo models, such as the rabbit elastase model, are commonly chosen for preclinical device testing; however, these studies are expensive, and aneurysm geometries are difficult to control and often do not replicate the variety of geometries found in clinical cases. A promising alternative for preclinical testing of neurovascular devices is an aneurysm blood vessel mimic (aBVM), which is an in vitro tissue-engineered model of a human blood vessel composed of an electrospun scaffold with an aneurysm geometry and human vascular cells. Previous work in the Cal Poly Tissue Engineering Lab has established a process for creating different aneurysm scaffolds based on the shape of different geometries, and this work aimed to further advance these aneurysm geometries in order to enhance the versatility of the in vitro model. The overall goal of this thesis was to customize the aBVM model through variations of different dimensions and to validate the scaffold variations for neurovascular device testing. First, a literature review was performed to identify critical ranges of aneurysm neck diameters and heights that are commonly seen in rabbit elastase models and in human clinical settings in order to set a foundation for creating new geometries. Based on the results, aneurysm geometries with varying neck sizes and heights were modeled and molded, and scaffolds were fabricated through electrospinning. Methods were developed to characterize scaffolds with internal measurements through imaging techniques using a scanning electron microscope. To validate these scaffolds for use as aBVMs for neurovascular device testing, constructs were created by dual-sodding human endothelial cells and smooth muscle cells into scaffolds with varying neck sizes. Finally, flow diverters were deployed in constructs with varying neck sizes in order to evaluate feasibility and initial healing. Customized aneurysm scaffolds can eventually be used with a variety of device studies for screening of neurovascular devices or as a predecessor for in vivo preclinical testing