Feijter, Pim

Krams, R (Rob)

Ligthart, JMR

Schuurbiers, JCH

Serruys, PWJC (Patrick)

Slager, CJ

Thury, A (Attila)

Wentzel, Jolanda

Undetermined

EUR Research Repository

EUR Research Information PortalProminent role of tensile stress in propagation of a dissection after coronary stenting:computational fluid dynamic analysis on true 3d- reconstructed segmentPublished in:CirculationPublication status and date:Published: 01/01/2001Document VersionPublisher's PDF, also known as Version of recordCitation for the published version (APA):Thury, A., Wentzel, J., Schuurbiers, JCH., Ligthart, JMR., Krams, R., Feijter, P., Serruys, PWJC., & Slager, CJ. (2001).Prominent role of tensile stress in propagation of a dissection after coronary stenting: computational fluid dynamic analysison true 3d- reconstructed segment. Circulation, 104, 53-54. http://hdl.handle.net/1765/9758Link to publication on the EUR Research Information PortalTerms and Conditions of UseExcept as permitted by the applicable copyright law, you may not reproduce or make this material available to any third partywithout the prior written permission from the copyright holder(s). Copyright law allows the following uses of this materialwithout prior permission:            • you may download, save and print a copy of this material for your personal use only;            • you may share the EUR portal link to this material.In case the material is published with an open access license (e.g. a Creative Commons (CC) license), other uses may beallowed. Please check the terms and conditions of the specific license.Take-down policyIf you believe that this material infringes your copyright and/or any other intellectual property rights, you may request itsremoval by contacting us at the following email address: openaccess.library@eur.nl. Please provide us with all the relevantinformation, including the reasons why you believe any of your rights have been infringed. In case of a legitimate complaint,we will make the material inaccessible and/or remove it from the website.ISSN: 1524-4539 Copyright © 2001 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online72514Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TXDOI: 10.1161/hc3601.095216  2001;104;53-54 CirculationKrams, Pim J. de Feyter, Patrick W. Serruys and Cornelis J. Slager Attila Thury, Jolanda J. Wentzel, Johan C.H. Schuurbiers, Jurgen M.R. Ligthart, Rob SegmentStenting: Computational Fluid Dynamic Analysis on True 3D-Reconstructed Prominent Role of Tensile Stress in Propagation of a Dissection After Coronary http://circ.ahajournals.org/cgi/content/full/104/11/e53located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/static/html/reprints.htmlReprints: Information about reprints can be found online at    journalpermissions@lww.comStreet, Baltimore, MD 21202-2436. Phone 410-5280-4050. Fax: 410-528-8550. Email: Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, 351 West Camden   http://circ.ahajournals.org/subsriptions/Subscriptions: Information about subscribing to Circulation is online at  at SWETS SUBS SERVICE on October 17, 2006 circ.ahajournals.orgDownloaded from Prominent Role of Tensile Stress in Propagation of aDissection After Coronary StentingComputational Fluid Dynamic Analysis on True 3D-Reconstructed SegmentAttila Thury, MD; Jolanda J. Wentzel, PhD; Johan C.H. Schuurbiers, BSc; Jurgen M.R. Ligthart, BSc;Rob Krams, MD, PhD; Pim J. de Feyter, MD, PhD; Patrick W. Serruys, MD, PhD; Cornelis J. Slager, PhDA61-year-old man underwent direct stenting in the mid rightcoronary artery with a 3.5318-mm stent deployed at apressure of 14 atm. Without further balloon inflation, the controlangiogram showed a stepdown-like pattern at the distal edge of thestent (Figure 1A). At that site, intravascular ultrasound (IVUS)imaging (see Movie, available at http://www.circulationaha.org)showed a ruptured plaque and a minor dissection. Shortly afterIVUS, the dissection extended distally and became subocclusive(Figure 1, B and C). Deployment of 2 additional stents arrestedpropagation of the dissection. The final angiogram showed asatisfactory result, with TIMI 3 flow. Despite the importance ofedge dissection, the mechanism of propagation in coronary arterieshas not been described. It seems reasonable that the pressure forceinduced by flow on a dissected flap would stimulate propagation.To study this flow-induced force, the coronary artery lumen andwall were reconstructed in true 3D (Figure 2A) by fusion ofangiographic and IVUS data. Application of computational fluiddynamics to the reconstruction visualized the pressure developmentin the axial direction (Figure 2B) as well as that over the crosssections surrounding the protruding flap (Figure 2C). The pressuredifference found between the intimal and luminal sides of the flap is'1 mm Hg. In contrast, with this low value, greater local changesin pressure and associated force can be deduced from the Laplaceequation applied to the changing morphology of the dissected vesselwall. Normally, the tensile force exerted by the fibrous cap andthickened intima creates a significant pressure drop from the lumento the subintimal space. This pressure drop is proportional to theratio of intima thickness to wall thickness, eg, for respectivethicknesses of 0.2 mm and 1 mm, this amounts to one fifth ofluminal pressure. In case of an intimal rupture, blood enters thesubintimal space. This eliminates the lumen-to-subintima pressuredrop and results in retraction of the inner vessel wall layers.Moreover, the outer wall layers then become exposed to the fullblood pressure and expand (Figure 2A). Both effects lead topropagation of the dissection. A similar mechanism has beendescribed for aortic dissection. Indeed, this also explains retrogradeexpansion of a dissection, as is frequently observed after balloondilatation. Nevertheless, a major flow-related difference betweenretrogradely or distally propagating dissections occurs when thedissection spreads circumferentially over.180°. Then, only fordistally propagating dissections, the flow-induced pressure differ-ence becomes important, because this forces the flap to flip over,thus causing a total vessel occlusion.From the Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam (all authors), and the Interuniversity Cardiology Institute(J.J.W.), Utrecht, Netherlands.Movie is available as a Data Supplement at http://www.circulationaha.orgReprint requests to C.J. Slager, PhD, Thoraxcenter EE 2322, Erasmus Medical Center Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands.E-mail slager@tch.fgg.eur.nlThe editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital andTexas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulationencourages readers to submit cardiovascular images to theCirculationEditorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute,6720 Bertner Ave, MC1-267, Houston, TX 77030.(Circulation. 2001;104:e53-e54.)© 2001 American Heart Association, Inc.Circulation is available at http://www.circulationaha.org1Images in Cardiovascular MedicineFigure 1. A, Angiographic left anterior oblique view of right cor-onary artery showing implanted 3.5318-mm stent (arrows) andmarked indentation (“stepdown”) at distal edge with good distalflow. B, Subocclusive dissection with TIMI 2 flow shortly afterIVUS pullback. C, Improved visualization of subocclusion. Ani-mated version: ECG-gated motorized pullback IVUS recording(0.5 mm/step) (ClearView, CVIS, Boston Scientific Corp, withUltraCross 30-MHz imaging catheter) shows cross sections ofartery from 3 mm downstream of distal edge of stent to 1 mmwithin stented segment. IVUS image shows a large fibrotic capbetween 2 o’clock and 7 o’clock positions, dissected over a1.5-mm length in longitudinal direction (arrow). Behind flap,motion of blood in cavity is visualized by moving speckles. Also,contrast remnants (black) can be recognized at 3 o’clockposition.Figure 2. A, 3D reconstruction of lumen (red) and wall ofstented and dissected part of right coronary artery. Stent (notvisualized) is immediately proximal (top of reconstruction) to dis-section. Outer surface represents external elastic membrane.Opened subintimal space was manually edited into reconstruc-tion for didactic purposes. Some local bulging of outer vesselwall after dissection can be recognized (arrow). B, Luminal meshfor application of computational fluid dynamics to solve Navier-Stokes equations and to derive from these spatial luminal pres-sure values. Pressure is calculated relative to exit cross section(bottom) and shown color coded at luminal wall. Total pressuredrop over segment was '1.5 mm Hg. For entrance flow condi-tion, a high mean velocity of 40 cm/s was selected to avoidunderestimation of flow-induced pressure effects. Blood wasmodeled as a Newtonian fluid with a viscosity of 3.531023 Pa ·s. C, Two cross-sectional planes are indicated at 1-mm dis-tance, 1 at distal stent edge and 1 at minimal lumen cross-sectional area caused by flap protruding into lumen. Color-coded planes show pressure distribution over lumen crosssections. A small local maximum in pressure (0.8 mm Hg) atmedial entrance of dissection can be observed. With currentmesh, pressure in subintimal space behind flap could not becalculated, but it may be assumed that this pressure nearlyequals that at dissection entrance regarding subintimal low-flow-velocity conditions. Interestingly, a negative pressure(20.4 mm Hg) has developed at luminal side of flap because offlow acceleration (Venturi effect). Resulting maximal difference inpressure between both sides of flap is only '1 mm Hg.2 Circulation September 11, 2001

Prominent role of tensile stress in propagation of a dissection after coronary stenting: computational fluid dynamic analysis on true 3d- reconstructed segment

https://pure.eur.nl/ws/files/46624247/11551889.pdf

Prominent role of tensile stress in propagation of a dissection after coronary stenting: computational fluid dynamic analysis on true 3d- reconstructed segment

Abstract

Similar works

Full text

Available Versions

EUR Research Repository