Comparison among different high porosity stent configurations: hemodynamic effects of treatment in a large cerebral aneurysm.

Whether treated surgically or with endovascular techniques, large and giant cerebral aneurysms are particularly difficult to treat. Nevertheless, high porosity stents can be used to accomplish stent-assisted coiling and even standalone stent-based treatments that have been shown to improve the occlusion of such aneurysms. Further, stent assisted coiling can reduce the incidence of complications that sometimes result from embolic coiling (e.g., neck remnants and thromboembolism). However, in treating cerebral aneurysms at bifurcation termini, it remains unclear which configuration of high porosity stents will result in the most advantageous hemodynamic environment. The goal of this study was to compare how three different stent configurations affected fluid dynamics in a large patient-specific aneurysm model. Three common stent configurations were deployed into the model: a half-Y, a full-Y, and a crossbar configuration. Particle image velocimetry was used to examine post-treatment flow patterns and quantify root-mean-squared velocity magnitude (VRMS) within the aneurysmal sac. While each configuration did reduce VRMS within the aneurysm, the full-Y configuration resulted in the greatest reduction across all flow conditions (an average of 56% with respect to the untreated case). The experimental results agreed well with clinical follow up after treatment with the full-Y configuration; there was evidence of thrombosis within the sac from the stents alone before coil embolization was performed. A computational simulation of the full-Y configuration aligned well with the experimental and in vivo findings, indicating potential for clinically useful prediction of post-treatment hemodynamics. This study found that applying different stent configurations resulted in considerably different fluid dynamics in an anatomically accurate aneurysm model and that the full-Y configuration performed best. The study indicates that knowledge of how stent configurations will affect post-treatment hemodynamics could be important in interventional planning and demonstrates the capability for such planning based on novel computational tools.

Flow diverter effect on cerebral aneurysm hemodynamics: an in vitro comparison of telescoping stents and the Pipeline.

INTRODUCTION: Flow diverting devices and stents can be used to treat cerebral aneurysms too difficult to treat with coiling or craniotomy and clipping. However, the hemodynamic effects of these devices have not been studied in depth. The objective of this study was to quantify and understand the fluid dynamic changes that occur within bifurcating aneurysms when treated with different devices and configurations. METHODS: Two physical models of bifurcating cerebral aneurysms were constructed: an idealized model and a patient-specific model. The models were treated with four device configurations: a single low-porosity Pipeline embolization device (PED) and one, two, and three high-porosity Enterprise stents deployed in a telescoping fashion. Particle image velocimetry was used to measure the fluid dynamics within the aneurysms; pressure was measured within the patient-specific model. RESULTS: The PED resulted in the greatest reductions in fluid dynamic activity within the aneurysm for both models. However, a configuration of three telescoping stents reduced the fluid dynamic activity within the aneurysm similarly to the PED treatment. Pressure within the patient-specific aneurysm did not show significant changes among the treatment configurations; however, the pressure difference across the untreated vessel side of the model was greatest with the PED. CONCLUSION: Treatment with stents and a flow diverter led to reductions in aneurysmal fluid dynamic activity for both idealized and patient-specific models. While the PED resulted in the greatest flow reductions, telescoping high-porosity stents performed similarly and may represent a viable treatment alternative in situations where the use of a PED is not an option.

In vitro and in silico study of intracranial stent treatments for cerebral aneurysms: effects on perforating vessel flows.

BACKGROUND: Many cerebral aneurysms can be treated effectively with intracranial stents. Unfortunately, stents can occlude perforating vessels near the treatment site which can decrease cerebral perfusion and increase the risk of stroke. METHODS: Particle image velocimetry was used to investigate the effects of intracranial stents on flows in perforators near a treated aneurysm. In Phase 1 of the study, different stent configurations were deployed into an idealized physical model of a sidewall aneurysm with perforating vessels. The configurations investigated were the Pipeline embolization device (PED) and one, two and three telescoping Neuroform stents. In Phase 2 of the study a single Neuroform stent was deployed so that the stent struts directly occluded the perforating vessel. RESULTS: In Phase 1 of the study it was found that even three telescoping stents affected perforating vessel flow less than a single PED under pulsatile conditions (average reduction 32.7% vs 46.5%). Results from Phase 2 indicated that the location of the occluding strut across the perforating vessel orifice had a greater impact on perforating vessel flow than the percentage occlusion. CONCLUSION: The findings of this study show that the use, configuration and positioning of intracranial stents can all have considerable influence on flow in affected perforating vessels near treated cerebral aneurysms.

An in vitro study of pulsatile fluid dynamics in intracranial aneurysm models treated with embolic coils and flow diverters.

Although coil embolization is one of the most effective treatments for intracranial aneurysms (ICAs), the procedure is often unsuccessful. For example, an ICA may persist after coil embolization if deployed coils fail to block the flow of blood into the aneurysm. Unfortunately, the specific flow changes that are effected by embolic coiling (and other endovascular therapies) are poorly understood, which creates a barrier to the design and execution of optimal treatments in the clinic. We present an in vitro pulsatile flow study of treated basilar tip aneurysm models that elucidates relationships between controllable treatment parameters and clinically important post-treatment fluid dynamics. We also compare fluid dynamic performance across embolic coils and more recently proposed devices (e.g., the Pipeline Embolization Device) that focus on treating ICAs by diverting rather than blocking blood flow. In agreement with previous steady flow studies, coil embolization-reduced velocity magnitude at the aneurysmal neck by greater percentages for a narrow-neck aneurysm, and reduced flow into aneurysms by greater percentages at lower parent vessel flow rates. However, flow diversion reduced flow into a wide-neck aneurysm more so than coil embolization, regardless of flow conditions. Finally, results also showed that for the endovascular devices we examined, treatment effects were generally less dramatic under physiologic pulsatile flow conditions as compared to steady flow conditions. The fluid dynamic performance data presented in this study represent the first direct in vitro comparison of coils and flow diverters in aneurysm models, and provide a novel, quantitative basis to aid in designing endovascular treatments toward specific fluid dynamic outcomes.

Flow visualization of a pediatric ventricular assist device during stroke volume reductions related to weaning.

The aim of this study is to define the fluid mechanics of a pulsatile pneumatically driven pediatric ventricular assist device (PVAD), for the reduced flow rates encountered during device weaning and myocardial recovery, and relate the results to the potential for thromboembolic events. We place an acrylic model of the PVAD in a mock circulatory loop filled with a viscoelastic blood analog and operate at four stroke volumes (SVs), each with two different filling conditions, to mimic how the flow rate of the device may be reduced. Particle image velocimetry is used to acquire flow field data. We find that a SV reduction method provides better rotational flow and higher wall shear rates than a beat rate reduction method; that a quick filling condition with a compressed diastolic time is better than a slow filling condition; and, that a reduction in SV to 40% led to greatly reduced fluid movement and wall shear rates that could increase the thrombogenicity of the device. SV reduction is a viable option for flow reduction during weaning, however, it does lead to significant changes to the device flow field and future studies are needed to develop operational protocols for the PVAD during bridge-to-recovery.

A parametric study of valve orientation on the flow patterns of the Penn State pulsatile pediatric ventricular assist device.

Because of the shortage of organs for transplant in pediatric patients with end-stage heart failure, Penn State is developing a pneumatically driven 12 cc pulsatile pediatric ventricular assist device (PVAD). A major concern is the flow field changes related to the volume decrease and its effect on device thrombogenicity. Previous studies of similar devices have shown that changes in the orientation of the inlet valve can lead to improvement in the flow field. Herein, the fluid dynamic effects of orientation changes at both the inlet and outlet valves are studied. Using two-dimensional particle image velocimetry, we examine the flow field in vitro using an acrylic model of the PVAD in a mock circulatory loop. Regardless of valve orientation, the overall flow pattern inside the PVAD remains similar, but important differences were seen locally in the wall shear rates, which is notable because shear rates >500 s may prevent thrombus formation. As the inlet valve was rotated toward the fluid side of the PVAD, we observed an increase in inlet jet velocity and wall shear rates along the inlet port wall. A corresponding rotation of the outlet valve increases the wall shear rate along the outer wall near the device outlet. Wall shear rates were all higher when both valves were rotated toward the fluid side of the device, with the best rates found at orientations of +15 degrees for both the inlet and outlet valves. Overall, orientations of +15 degrees or +30 degrees of both the inlet and outlet valve resulted in an increase in wall shear rates and could aid in the reduction of thrombus formation inside the PVAD.

The influence of operational protocol on the fluid dynamics in the 12 cc Penn state pulsatile pediatric ventricular assist device: the effect of end-diastolic delay.

The success of adult ventricular assist devices (VADs), coupled with the high transplant waiting list mortality of infants (40%) has prompted Penn State to develop a pediatric version of the clinically successful adult device. Although the primary use of this device will be bridge-to-transplant, there has been sufficient clinical data to demonstrate the efficacy of VADs in a bridge-to-recovery setting. However, removing the patient from the device, a process known as weaning, demands operation of the device at a lower beat rate and concomitant increased risk for thromboembolism. Previous studies have shown that the interrelated flow characteristics necessary for the prevention of thrombosis in a pulsatile VAD are a strong inlet jet, a late diastolic recirculating flow, and a wall shear rate greater than 500/s. In an effort to develop a strong inlet jet and rotational flow pattern at a lower beat and flow rate, we have compressed diastole by altering the end-diastolic delay time (EDD). Particle image velocimetry was used to compare the flow fields and wall shear rates in the chamber of the 12 cc Penn State pulsatile pediatric VAD operated at 50 beats per minute using EDDs of 10, 50, and 100 ms. Although we expected the 100 ms EDD to have the best wall shear profiles, we found that the 50 ms EDD condition was superior to both the 10 and 100 EDD conditions, due to a longer sustained inlet jet.

Flow visualization of three-dimensionality inside the 12 cc Penn State pulsatile pediatric ventricular assist device.

In order to aid the ongoing concern of limited organ availability for pediatric heart transplants, Penn State has continued development of a pulsatile Pediatric Ventricular Assist Device (PVAD). Initial studies of the PVAD observed an increase in thrombus formation due to differences in flow field physics when compared to adult sized devices, which included a higher degree of three-dimensionality. This unique flow field brings into question the use of 2D planar particle image velocimetry (PIV) as a flow visualization technique, however the small size and high curvature of the PVAD make other tools such as stereoscopic PIV impractical. In order to test the reliability of the 2D results, we perform a pseudo-3D PIV study using planes both parallel and normal to the diaphragm employing a mock circulatory loop containing a viscoelastic fluid that mimics 40% hematocrit blood. We find that while the third component of velocity is extremely helpful to a physical understanding of the flow, particularly of the diastolic jet and the development of a desired rotational pattern, the flow data taken parallel to the diaphragm is sufficient to describe the wall shear rates, a critical aspect to the study of thrombosis and design of such pumps.

The 12 cc Penn State pulsatile pediatric ventricular assist device: fluid dynamics associated with valve selection.

The mortality rate for infants awaiting a heart transplant is 40% because of the extremely limited number of donor organs. Ventricular assist devices (VADs), a common bridge-to-transplant solution in adults, are becoming a viable option for pediatric patients. A major obstacle faced by VAD designers is thromboembolism. Previous studies have shown that the interrelated flow characteristics necessary for the prevention of thrombosis in a pulsatile VAD are a strong inlet jet, a late diastolic recirculating flow, and a wall shear rate greater than 500 s(-1). Particle image velocimetry was used to compare the flow fields in the chamber of the 12 cc Penn State pediatric pulsatile VAD using two mechanical heart valves: Bjork-Shiley monostrut (BSM) tilting disk valves and CarboMedics (CM) bileaflet valves. In conjunction with the flow evaluation, wall shear data were calculated and analyzed to help quantify wall washing. The major orifice inlet jet of the device containing BSM valves was more intense, which led to better recirculation and wall washing than the three jets produced by the CM valves. Regurgitation through the CM valve served as a significant hindrance to the development of the rotational flow.

The 12 cc Penn State pulsatile pediatric ventricular assist device: flow field observations at a reduced beat rate with application to weaning.

Ventricular assist devices (VADs) have become a viable option for adult patients with end-stage heart failure during the bridge-to-transplant period and have recently shown promise in aiding in myocardial recovery. Because the number of available organs is insufficient, mechanical circulatory support systems such as VADs are also being developed for use in pediatric patients. During myocardial recovery, the system must be weaned from the patient to prepare for explant; for pulsatile devices, this often includes a reduction in flow rate, which can change the fluid dynamics of the device. These changes in flow need to be monitored because strong diastolic rotational flow, no areas of blood stasis, low blood residence time, and wall shear rates above 500 s, can help prevent thrombus deposition. Particle image velocimetry was used to observe the planar flow patterns and wall shear rates of the 12 cc Penn State Pneumatic Pediatric VAD (PVAD) at a normal operating condition and a reduced beat rate. At the reduced beat rate, the PVAD showed an earlier loss of rotational pattern, increased blood residence time, and an overall reduction in wall shear rate at the outer walls. Because this reduction in flow rate could lead to a possible increase in thrombus deposition, it may be necessary to look into other options for weaning a patient from the PVAD.