Incomplete stent expansion in flow-diversion treatment affects aneurysmal haemodynamics: a quantitative comparison of treatments affected by different severities of malapposition occurring in different segments of the parent artery.

Incomplete stent expansion (IncSE) is occasionally seen in flow-diversion (FD) treatment of intracranial aneurysms; however, its haemodynamic consequences remain inconclusive. Through a parametric study, we quantify the aneurysmal haemodynamics subject to different severities of IncSE occurring in different portions of the stent. Two patient cases with IncSE confirmed in vivo were studied. To investigate a wider variety of IncSE scenarios, we modelled IncSE at two severity levels respectively located in the proximal, central, or distal segment of a stent, yielding a total of 14 treatment scenarios (including the ideal deployment). We examined stent wire configurations in 14 scenarios and resolved aneurysm haemodynamics through computational fluid dynamics (CFD). A considerable degradation of aneurysm flow-reduction performance was observed when central or distal IncSE occurred, with the maximal elevations of the inflow rate (IR) and energy loss (EL) being 10% and 15%. The underlying mechanism might be the increased resistance for flow to remain within the FD stent, which forces more blood to leak into the aneurysm sac. Counter-intuitively, a slight reduction of aneurysm inflow was associated with proximal IncSE, with the maximal further reduction of the IR and EL being 5% and 8%. This may be due to the disruption of the predominant parent-artery flow by the collapsed wires, which decreased the strength and altered the direction of aneurysmal inflow. The effects of IncSE vary greatly with the location of occurrence, revealing the importance of performing individualised, patient-specific risk assessment before treatment.

CTA-Based Non-invasive Estimation of Pressure Gradients Across a CoA: a Validation Against Cardiac Catheterisation.

Non-invasive estimation of pressure gradients across a coarctation of the aorta (CoA) can reduce the need for diagnostic cardiac catheterisation. We aimed to validate two novel computational strategies-target-value approaching (TVA) and target-value fixing (TVF)-together with unrefined Doppler estimates, and to compare their diagnostic performance in identifying critical pressure drops for 40 patients. Compared to catheterisation, no statistically significant difference was demonstrated with TVA (P = 0.086), in contrast to TVF (P = 0.005) and unrefined Doppler echocardiography (P < 0.001). TVA manifested the strongest correlation with catheterisation (r = 0.93), compared to TVF (r = 0.83) and echocardiography (r = 0.67) (all P < 0.001). In discriminating pressure gradients greater than 20 mmHg, TVA, TVF, and echocardiography had respective sensitivities of 0.92, 0.88, and 0.80; specificities of 0.93, 0.80, and 0.73; and AUCs of 0.96, 0.89, and 0.80. The TVA strategy may serve as an effective and easily implemented approach to be used in clinical management of patients with CoA. Graphical Abstract Central illustration. Pressure gradients estimated using Doppler echocardiography and two novel computational strategies (TVA and TVF) were compared with cardiac catheterisation for 40 patients. TVA and TVF utilised the CTA images to obtain the CoA anatomy and Doppler echocardiography velocimetry to obtain velocity data for the assignment of CFD boundary conditions.

A pilot validation of CFD model results against PIV observations of haemodynamics in intracranial aneurysms treated with flow-diverting stents.

Flow-diverting (FD) stents are one of three common modes of treating intracranial aneurysms, yet knowledge of their effect on haemodynamics is incomplete. We used particle image velocimetry (PIV) to measure spatially-varying velocity of blood-analogue fluid within a patient-specific aneurysm model, and compared the observed flow behaviour to predictions from a computational fluid dynamics (CFD) model. In PIV experiments we characterised the flow on multiple cross-sections for three different arterial flowrates (150, 250, 400 mL/min) after deployment of a commercially-available FD stent. Our flow-diverting (FD) stent model for CFD simulation was constructed using a permeability adapted from the literature. Aneurysmal haemodynamics without the FD stent treatment provided good similarities between CFD and PIV results, and the results with a Silk stent treatment also provided acceptable concordances, thereby validating the use of CFD as a convenient and flexible tool for investigating intra-aneurysmal flow dynamics after FD stent treatment. Furthermore, for the first time, the porous-medium FD model stent was validated to be both efficient and effective to predict the flow-diversion effects of a FD stent treatment with a patient-specific intracranial aneurysm. Through the qualitative and quantitative comparison of CFD predictions against the experimental outcomes, this study gives confidence for future studies on aneurysmal haemodynamics and FD stent treatment effects to use CFD simulation.

Numerical simulation of aneurysmal haemodynamics with calibrated porous-medium models of flow-diverting stents.

Modelling flow-diverting (FD) stents as porous media (PM) markedly improves the efficiency of computational fluid dynamics (CFD) simulations in the study of intracranial aneurysm treatment. Nonetheless, the parameters of PM models adopted for simulations up until now were rarely calibrated to match the represented FD structure. We therefore sought to evaluate the PM parameters for a representative variety of commercially available stents, so characterising the flow-diversion behaviours of different FD devices on the market. We generated fully-resolved geometries for treatments using PED, Silk+, FRED, and dual PED stents. We then correspondingly derived the calibrated PM parameters-permeability (k) and inertial resistance factor (C2)-for each stent design from CFD simulations, to ensure the calibrated PM model has identical flow resistance to the FD stent it represents. With each of the calibrated PM models respectively deployed in two aneurysms, we studied the flow-diversion effects of these stent configurations. This work for the first time reported several sets of parameters for PM models, which is vital to address the current knowledge gap and rectify the errors in PM model simulations, thereby setting right the modelling protocol for future studies using PM models. The flow resistance parameters were strongly affected by porosity and effective thickness of the commercial stents, and thus accounted for in the PM models. Flow simulations using the PM stent models revealed differences in aneurysmal mass flowrate (MFR) and energy loss (EL) between various stent designs. This study improves the practicability of FD simulation by using calibrated PM models, providing an individualised method with improved simulation efficiency and accuracy.

Applying computer simulation to the design of flow-diversion treatment for intracranial aneurysms.

Although flow-diversion (FD) treatment has been proven to be able to induce intracranial aneurysm (IA) occlusion, clinical follow-ups reported that a number of patients may still suffer from delayed IA rupture or incomplete aneurysm occlusion post-treatment. Complete aneurysm occlusion is believed to be associated with favourable haemodynamic alteration post-treatment, which may be greatly affected by the selection of device size and quantity, as well as the FD deployment procedure. However, clinicians have to choose and deploy the FD relying on their experience, since no post-stenting haemodynamic information is generally available to them prior to a specific treatment. In this study, using a virtual FD deployment technique and computational fluid dynamics method, we demonstrate and compare the haemodynamic changes after virtual FD treatments using a variety of prospective treating strategies.

Sensitivity study on modelling a flow-diverting stent as a porous medium using computational fluid dynamics.

The flow-diverting (FD) stent has become a commonly used endovascular device to treat cerebral aneurysms. This discourages blood from entering the aneurysm, thereby reducing the likelihood of aneurysm rupture. Using computational fluid dynamics (CFD) to simulate the aneurysmal haemodynamics after FD treatment could help clinicians predict the stent effectiveness prior to the real procedure in the patient. As an alternative to modelling the stent as a fine wire mesh, modelling the FD stent as a porous medium was established to save computational time, and has also been proved capable of predicting the same haemodynamics as obtained using the real FD stent geometry. The flow resistance effect of a porous-medium stent may differ with respect to its morphology or permeability; however, the flow resistance effect after adjusting these parameters had not been clarified. In this study, we analysed the haemodynamic changes caused by alterations of porous-medium thickness and permeability, thereby providing future porous-medium stent simulations with important information on the respective parametric sensitivities. We found significant sensitivity to permeability. Results were insensitive to thickness when permeability was adjusted beforehand to compensate. We also compared our results with observations from an in-vitro model, and found good agreement. This supports adoption of porous-medium models in future work.

Haemodynamic effects of stent diameter and compaction ratio on flow-diversion treatment of intracranial aneurysms: A numerical study of a successful and an unsuccessful case.

BACKGROUND: Compacting a flow-diverting (FD) stent is an emerging technique to create a denser configuration of wires across the aneurysm ostium. However, quantitative analyses of post-stenting haemodynamics affected by the compaction level of different stent sizes remain inconclusive. OBJECTIVE: To compare the aneurysmal haemodynamic alterations after virtual FD treatments with different device diameters at different compaction ratios. METHODS: We virtually implanted three sizes of FD stent, with each size deployed at four compaction ratios, into two patient aneurysms previously treated with the Silk+FD-one successful case and the other unsuccessful. Wire configurations of the FD in the 24 treatment scenarios were examined, and aneurysmal haemodynamic alterations were resolved by computational fluid dynamics (CFD) simulations. We investigated the aneurysmal flow patterns, aneurysmal average velocity (AAV), mass flowrate (MF), and energy loss (EL) in each scenario. RESULTS: Compactions of the stent in the successful case resulted in a greater metal coverage rate than that achieved in the unsuccessful one. A 25% increment in compaction ratio further decreased the AAV (12%), MF (11%), and EL (9%) in both cases (average values). The averaged maximum differences attributable to device size were 10% (AAV), 8% (MF), and 9% (EL). CONCLUSIONS: Both stent size and compaction level could markedly affect the FD treatment outcomes. It is therefore important to individualise the treatment plan by selecting the optimal stent size and deployment procedure. CFD simulation can be used to investigate the treatment outcomes, thereby assisting doctors in choosing a favourable treatment plan.

Intraoperative tremor in surgeons and trainees.

OBJECTIVES: Tremor may be expected to interfere with the performance of fine motor tasks such as surgery. While tremor is readily quantified in inactive subjects, it is more challenging to measure tremor as the subjects perform complex tasks. The objective of this work was to quantify tremor during the performance of a realistic simulated surgery. METHODS: Our novel surgical simulator incorporates a force sensor that allows identification and quantification of the intraoperative effects of tremor on the manipulandum. We have collected preliminary data from trainees and experienced surgeons carrying out multiple simulated anastomoses on silicone vessels, mimicking a procedure such as distal coronary anastomosis. We calculated transient and overall tremor intensity, and tested for a hypothesized 'learning effect'. RESULTS: Several of the recordings of intraoperative force data manifested distinctive features corresponding to substantial oscillation in the range of 8-12 Hz. We attribute this to enhanced physiological tremor. These early results indicate a significant reduction in the transmission of surgeon's tremor to the operative field from the first attempt to later attempts (P = 0.039, standardized effect size = 0.91), which may be associated with increasing confidence. CONCLUSIONS: This new method does not just quantify tremor, but quantifies the transmission of tremor to a manipulandum in the operative field during high-fidelity simulated coronary surgery. This may be used to assess and provide feedback on the performance of trainees and experienced surgeons, along with other fields in which fine motor skills are of vital importance.

Measurement of tremor transmission during microsurgery.

BACKGROUND: Tremor is a major impediment to performing fine motor tasks, as in microsurgery. However, conventional measurements do not involve tasks representative of microsurgery. METHOD: We developed a low-cost surgical simulator incorporating a force transducer capable of detecting and quantifying the effects of tremor upon high-fidelity silicone replicas of cardiac vessels and substrate muscle. Experienced and trainee surgeons performed simulated anastomoses on this rig. We characterized procedures in terms of tremor intensity, based on Lomb-Scargle periodograms. RESULTS: Distinctive force oscillations occurred at 8-12 Hz, characteristic of enhanced physiological tremor, yielding peaks in power spectral density. These early results suggest a significantly lower transmission of tremor to the operative field by the experienced surgeon in comparison to the trainees. CONCLUSIONS: This new device quantifies the action of tremor upon a manipulandum during a complex task, which may be used for assessment and providing feedback to trainee surgeons. Copyright © 2015 John Wiley & Sons, Ltd.

Assessing dewatering performance of drinking water treatment sludges.

A comparison of the dewaterability of a range of water treatment plant sludges has been completed through computation of dewatering performance indicators for a diaphragm filter press. Real parameter data, obtained from the characterisation of alum and ferric sludges, generated under precisely controlled conditions, was used for input to a phenomenological model. Comparisons of dewaterability based on throughput curves largely agree with previous analysis of the underlying parameter data. The difference in approach provides a quantification of benefit. Greater throughputs and output concentrations are predicted at the lowest coagulant doses and at pH approximately 6. Typical industrial cloth resistances consistently reduce throughput by a factor of 3-7, but the assessment of relative benefit is shown to be insensitive to this parameter. Quantitative agreement of the predictions with observed performance can be attained. Finally, the twin effects of solids loading and dewaterability are assessed together, showing that each has a significant influence on the required filter surface area. This quantification shows that high coagulant doses adversely affect both of these aspects, leading to filter area requirements larger than might otherwise be expected.