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ResumenEl hombro es uno de los Sistemas articulares más complejo del cuerpo humano. Conocer su funcionamiento es primordial para entender la biomecánica del cuerpo. El propósito de este estudio ha sido el de analizar la influencia de los Sistemas de Coordenadas Locales en la interpretación de los valores cinemáticos de la articulación GlenoHumeral. Se ha utilizado para ello un método invasivo, colocando pines trabeculares en el hombro y la escápula. El rastreo del movimiento se ha realizado mediante el uso de sensores pasivos. El procesamiento de los datos se ha efectuado mediante el uso de la plataforma de software libre pyFormex. Los desplazamientos de la articulación se han determinado mediante dos variantes diferentes de Sistemas de Coordenadas, detectándose una diferencia de 2 a 12 grados.AbstractThe shoulder is one of the most complex systems in the human body. To know how its work is essential to understand the biomechanics of the body. The purpose of this study was to analyze the influence of Local Coordinate Systems in the kinematic analysis of GlenoHumeral joint. The motion tracking was performed using passive sensors attached to pins. Trabecular pins were placed on the shoulder and scapula. The data processing was performed using the free open software pyFormex. The joint displacements were determined by two different variants of Coordinate Systems, being detected a difference from 2 to 12 degrees.

Excellence in either sprinting or endurance running requires specific musculo-skeletal characteristics of the legs. This study aims to investigate the morphology of the leg of sprinters and endurance runners of Caucasian ethnicity. Eight male sprinters and 11 male endurance runners volunteered to participate in this cross-sectional study. They underwent magnetic resonance imaging and after data collection, digital reconstruction was done to calculate muscle volumes and bone lengths. Sprinters have a higher total upper leg volume compared to endurance runners (7340 vs 6265 cm3). Specifically, the rectus femoris, vastus lateralis, and hamstrings showed significantly higher muscle volumes in the sprint group. For the lower leg, only a higher muscle volume was found in the gastrocnemius lateralis for the sprinters. No differences were found in muscle volume distribution, center of mass in the different muscles, or relative bone lengths. There was a significant positive correlation between ratio hamstrings/quadriceps volume and best running performance in the sprint group. Sprinters and endurance runners of Caucasian ethnicity showed the greatest distinctions in muscle volumes, rather than in muscle distributions or skeletal measures. Sprinters show higher volumes in mainly the proximal and lateral leg muscles than endurance runners.

With cardiovascular disease (CVD) remaining the primary cause of death worldwide, early detection of CVDs becomes essential. The intracardiac flow is an important component of ventricular function, motion kinetics, wash-out of ventricular chambers, and ventricular energetics. Coupling between Computational Fluid Dynamics (CFD) simulations and medical images can play a fundamental role in terms of patient-specific diagnostic tools. From a technical perspective, CFD simulations with moving boundaries could easily lead to negative volumes errors and the sudden failure of the simulation. The generation of high-quality 4D meshes (3D in space + time) with 1-to-1 vertex becomes essential to perform a CFD simulation with moving boundaries. In this context, we developed a semiautomatic morphing tool able to create 4D high-quality structured meshes starting from a segmented 4D dataset. To prove the versatility and efficiency, the method was tested on three different 4D datasets (Ultrasound, MRI, and CT) by evaluating the quality and accuracy of the resulting 4D meshes. Furthermore, an estimation of some physiological quantities is accomplished for the 4D CT reconstruction. Future research will aim at extending the region of interest, further automation of the meshing algorithm, and generating structured hexahedral mesh models both for the blood and myocardial volume.

Bioresorbable stents represent an emerging technological development within the field of cardiovascular angioplasty. Their temporary presence avoids long-term side effects of non-degradable stents such as in-stent restenosis, late stent thrombosis and fatigue induced strut fracture. Several numerical modelling strategies have been proposed to evaluate the transitional mechanical characteristics of biodegradable stents using a continuum damage framework. However, these methods rely on an explicit finite-element integration scheme which, in combination with the quasi-static nature of many simulations involving stents and the small element size needed to model corrosion mechanisms, results in a high computational cost. To reduce the simulation times and to expand the general applicability of these degradation models, this paper investigates an implicit finite element solution method to model degradation of biodegradable stents.

The trend towards realistic numerical models of (pathologic) patient-specific vascular structures brings along larger computational domains and more complex geometries, increasing both the computation time and the operator time. Hexahedral grids effectively lower the computational run time and the required computational infrastructure, but at high cost in terms of operator time and minimal cell quality, especially when the computational analyses are targeting complex geometries such as aneurysm necks, severe stenoses and bifurcations. Moreover, such grids generally do not allow local refinements. As an attempt to overcome these limitations, a novel approach to hexahedral meshing is proposed in this paper, which combines the automated generation of multi-block structures with a grid-based method. The robustness of the novel approach is tested on common complex geometries, such as tree-like structures (including trifurcations), stenoses, and aneurysms. Additionally, the performance of the generated grid is assessed using two numerical examples. In the first example, a grid sensitivity analysis is performed for blood flow simulated in an abdominal mouse aorta and compared to tetrahedral grids with a prismatic boundary layer. In the second example, the fluid-structure interaction in a model of an aorta with aortic coarctation is simulated and the effect of local grid refinement is analyzed.

ResumenLa descripción del comportamiento mecánico de tejidos duros mediante el empleo de modelos discretos pasa por diferentes etapas de análisis, desde el procesamiento digital de la imagen hasta la especificación de las propiedades físicas del tejido. Para ello, es necesario tener en cuenta un elemento clave: la descomposición del modelo en sus partes constitutivas. Se realizó un estudio bibliográfico de diversas propuestas para realizar la descomposición y se llegó a la conclusión de la inexistencia de una estrategia única. Existe un cúmulo de propuestas genéricas, pero estas no ofrecen una solución válida a los casos analizados, correspondientes a las articulaciones de la rodilla, la pelvis y el hombro. Por tanto, se propone un algoritmo para realizar la descomposición mediante el análisis de las relaciones espaciales entre los contornos presentes en planos consecutivos, que se basa en 4 etapas: la lectura de los cortes de imágenes de tomografía computarizada; la determinación de los contornos que definen el tejido óseo presente en cada corte; el agrupamiento de los contornos cuya relación espacial cumple un criterio determinado, y la eliminación de los volúmenes no válidos.Los resultados del algoritmo se compararon con otros obtenidos mediante el empleo de la librería Visualization ToolKit (VTK) y pyFormex, cuyos métodos se utilizan en la visualización y análisis de imágenes médicas y en la modelación de estructuras tridimensionales. Como resultado del algoritmo propuesto tenemos —bajo las mismas condiciones y en un corto tiempo de procesamiento— una descomposición de los modelos anatómicos superior a la realizada por VTK y pyFormex, con aproximadamente el 90% de confianza.AbstractDescription of mechanical behavior of hard tissues by means of discrete models goes through various stages of analysis, which range from digital image processing to the specification of physical properties of tissue to the discrete model. This requires taking into account a key element: the decomposition of the model into its constituent parts. We conducted a bibliographic study of existing proposals for such decomposition, leading to the conclusion of the absence of a single strategy. There are several generic proposals, but these proved not to give a valid solution applicable to the cases examined corresponding to the articulations of the knee, hip and shoulder. In this paper we propose an algorithm to perform this decomposition by analyzing the spatial relationships between the contours present in consecutive planes. It is based on four stages: reading computer tomography (CT) slices; determining the contours that define bone tissue present on each slice; grouping of contours whose relationship meets a given criterion; and eliminating non-valid volumes.Results were compared with those obtained by means of Visualization ToolKit (VTK) and pyFormex, widely used in the visualization and analysis of medical imaging and modeling three-dimensional structures. As a main result, proposed algorithm under the same conditions and short processing time performs a better decomposition of anatomical models than the one made by VTK and pyFormex, with about a 90% of confidence.

Despite all technological innovations in esophageal stent design over the past 20 years, the association between the stent design’s mechanical behavior and its effect on the clinical outcome has not yet been thoroughly explored. A parametric numerical model of a commercially available esophageal bioresorbable polymeric braided wire stent is set up, accounting for stent design aspects such as braiding angle, strut material, wire thickness, degradation and friction between the wires comprising a predictive tool on the device’s mechanical behavior. Combining this tool with complex multilayered numerical models of the pathological in vivo stressed, actively contracting and buckling esophagus could provide clinicians and engineers with a patient-specific window into the mechanical aspects of stent-based esophageal intervention. This study integrates device and soft tissue mechanics in one computational framework to potentially aid in the understanding of the occurrence of specific symptoms and complications after stent placement.

Endovascular treatment for patients with a proximal neck anatomy outside instructions for use is an ongoing topic of debate in endovascular aneurysm repair. This paper employs the finite element method to offer insight into possible adverse effects of deploying a stent graft into an angulated geometry. The effect of angulation, straight neck length and device oversize was investigated in a full factorial parametric analysis. Stent apposition, area reduction of the graft, asymmetry of contact forces and the ability to find a good seal were investigated. Most adverse effects are expected for combinations of high angulation and short straight landing zones. Higher oversize has a beneficiary effect, but not enough to compensate the adverse effects of (very) short and angulated angles. Our analysis shows that for an angle between the suprarenal aorta and proximal neck above 60°, proximal kinking of the device can occur. The method used offers a engineering view on the morphological limits of EVAR for a clinically used device.

Purpose Carotid artery stenting (CAS) is an alternative procedure for the treatment of severely stenosed carotid artery lesions in high-risk patients. Appropriate patient selection and stent design are paramount to achieve a low stroke and death rate in these complex high-risk procedures. This study introduces and evaluates a novel virtual, patient-specific, pre-operative environment to quantify scaffolding parameters based on routine imaging techniques. Methods Two patients who underwent CAS with two different sizes of the Acculink stent (Abbott Vascular, Santa Clara, CA, USA) were studied. Pre-operative data were used to build the numerical models for the virtual procedure. Numerical results were validated with post-operative angiography. Using novel virtual geometrical tools, incomplete stent apposition, free cell area and largest fitting sphere in the stent cell were evaluated in situ as quantitative measures of successful stent placement and to assess potential risk factors for CAS complications. Results A quantitative validation of the numerical outcome with post-operative images noted differences in lumen diameter of 5.31 ± 8.05% and 4.12 ± 9.84%, demonstrating the reliability of the proposed methodology. The quantitative measurements of the scaffolding parameters on the virtually deployed stent geometry highlight the variability of the device behavior in relation to the target lesion. The free cell area depends on the target diameter and oversizing, while the largest fitting spheres and apposition values are influenced by the local concavity and convexity of the vessel. Conclusions The proposed virtual environment may be an additional tool for endovascular specialists especially in complex anatomical cases where stent design and positioning may have a higher impact on procedural success and outcome.

Resumen El tejido oseo es el elemento principal del esqueleto. Sirve de soporte a las partes blandas, protege organos vitales y constituye un sistema de palancas que amplifica las fuerzas generadas durante la contraccion muscular. La descripcion del comportamiento mecanico del tejido oseo, mediante el empleo de modelos discretos, pasa por diferentes etapas de analisis, las cuales van desde el procesamiento digital de la imagen hasta la especificacion de las propiedades fisicas del tejido al modelo discreto, siendo la descomposicion de estos modelos en sus partes constitutivas un elemento clave. En la presente investigacion se discute un metodo para la descripcion geometrica de los huesos a partir de una secuencia de imagenes de tomografia computarizada y basado en la combinacion de la umbralizacion global y adaptativa. Los resultados obtenidos demostraron que este metodo constituye una propuesta efectiva al problema del volumen parcial y la separacion de los huesos en las articulaciones.

Objectives This study sought to better understand and optimize provisional main vessel stenting with final kissing balloon dilation (FKBD). Background Main vessel stenting with FKBD is widely used, but many technical variations are possible that may affect the final result. Furthermore, most contemporary stent designs have a large cell size, making the impact of stent platform selection for this procedure unclear. Methods Finite element simulations were used to virtually deploy and post-dilate 3 stent platforms in 3 bifurcation models. Two FKBD strategies were evaluated: simultaneous FKBD (n = 27) and modified FKBD (n = 27). In the simultaneous FKDB technique, both balloons were simultaneously inflated and deflated. In the modified FKBD technique, the side branch balloon was inflated first, then partially deflated, followed by main branch balloon inflation. Results Modified FKBD results in less ostial stenosis compared with simultaneous FKBD (15 ± 9% vs. 20 ± 11%; p Conclusions The modified FKBD procedure reduces elliptical stent deformation and optimizes side branch access.

The presented study details a combined experimental and computational method to assess and compare the mechanical behavior of the main body of 4 different stent graft designs. The mechanical response to a flat plate compression and radial crimping of the devices is derived and related to geometrical and material features of different stent designs. The finite element modeling procedure is used to complement the experimental results and conduct a solution sensitivity study. Finite element evaluations of the mechanical behavior match well with experimental findings and are used as a quantitative basis to discuss design characteristics of the different devices.

In vivo visualization of cardiovascular structures is possible using medical images. However, one has to realize that the resulting 3D geometries correspond to in vivo conditions. This entails an internal stress state to be present in the in vivo measured geometry of e.g. a blood vessel due to the presence of the blood pressure. In order to correct for this in vivo stress, this paper presents an inverse method to restore the original zero-pressure geometry of a structure, and to recover the in vivo stress field of the final, loaded structure. The proposed backward displacement method is able to solve the inverse problem iteratively using fixed point iterations, but can be significantly accelerated by a quasi-Newton technique in which a least-squares model is used to approximate the inverse of the Jacobian. The here proposed backward displacement method allows for a straightforward implementation of the algorithm in combination with existing structural solvers, even if the structural solver is a black box, as only an update of the coordinates of the mesh needs to be performed.

Carotid artery stenting (CAS) has emerged as a minimally invasive alternative to endarterectomy but its use in clinical treatment is limited due to the post-stenting complications. Haemodynamic actors, related to blood flow in the stented vessel, have been suggested to play a role in the endothelium response to stenting, including adverse reactions such as in-stent restenosis and late thrombosis. Accessing the flow-related shear forces acting on the endothelium in vivo requires space and time resolutions which are currently not achievable with non-invasive clinical imaging techniques but can be obtained from image-based computational analysis. In this study, we present a framework for accurate determination of the wall shear stress (WSS) in a mildly stenosed carotid artery after the implantation of a stent, resembling the commercially available Acculink (Abbott Laboratories, Abbott Park, Illinois, USA). Starting from angiographic CT images of the vessel lumen and a micro-CT scan of the stent, a finite element analysis is carried out in order to deploy the stent in the vessel, reproducing CAS in silico. Then, based on the post-stenting anatomy, the vessel is perfused using a set of boundary conditions: total pressure is applied at the inlet, and impedances that are assumed to be insensitive to the presence of the stent are imposed at the outlets. Evaluation of the CAS outcome from a geometrical and haemodynamic perspective shows the presence of atheroprone regions (low time-average WSS, high relative residence time) colocalised with stent malapposition and stent strut interconnections. Stent struts remain unapposed in the ostium of the external carotid artery disturbing the flow and generating abnormal shear forces, which could trigger thromboembolic events.

The aim of this study is to analyze the shape and flow changes of a patient-specific carotid artery after carotid artery stenting (CAS) performed using an open-cell (stent-O) or a closed-cell (stent-C) stent design. First, a stent reconstructed from micro-computed tomography (microCT) is virtually implanted in a left carotid artery reconstructed from CT angiography. Second, an objective analysis of the stent-to-vessel apposition is used to quantify the lumen cross-sectional area and the incomplete stent apposition (ISA). Third, the carotid artery lumen is virtually perfused in order to quantify its resistance to flow and its exposure to atherogenic or thrombogenic hemodynamic conditions. After CAS, the minimum cross-sectional area of the internal carotid artery (ICA) (external carotid artery [ECA]) changes by +54% (-12%) with stent-O and +78% (-17%) with stent-C; the resistance to flow of the ICA (ECA) changes by -21% (+13%) with stent-O and -26% (+18%) with stent-C. Both stent designs suffer from ISA but the malapposed stent area is larger with stent-O than stent-C (29.5 vs. 14.8 mm(2)). The untreated vessel is not exposed to atherogenic flow conditions whereas an area of 67.6 mm(2) (104.9) occurs with stent-O (stent-C). The area of the stent surface exposed to thrombogenic risk is 5.42 mm(2) (7.7) with stent-O (stent-C). The computer simulations of stenting in a patient's carotid artery reveal a trade-off between cross-sectional size and flow resistance of the ICA (enlarged and circularized) and the ECA (narrowed and ovalized). Such a trade-off, together with malapposition, atherogenic risk, and thrombogenic risk is stent-design dependent.

Stroke is a heterogeneous disease caused by a sustained interruption of the blood supply to part of the brain. Prevention and treatment of this disease is of primary importance as it has been estimated to be the second leading cause of death worldwide. Due to the large number of possible origins there is no general strategy for preventive treatment and evidence based recommendations are given. However major causes of stroke can be confined to few vascular districts. More and more evidence is supporting the hypothesis that biomechanical and hemodynamic parameters can be related to catastrophic cerebrovascular events. In this context structural and fluidodynamic computer simulations offer an optimal tool to quantify these predictors. On the other hand the advances in medical imaging allow providing realistic in vivo conditions (such as reliable anatomical geometries and initial mechanical state) for patient specific analysis. This paper reviews the progress and the state of art of numerical simulation used to analyze the early stages and the progression of the disease as well as their potential as tool for risk assessment, for treatment outcome and procedure planning.

AIMS: Mechanisms of lumen compromise after provisional side branch (SB) stenting are poorly understood. In this study we aimed to investigate the impact of bifurcation angle, plaque composition, and procedural strategy on SB compromise. METHODS AND RESULTS: Computer simulations of stent implantation were performed in Medina (1,1,1) bifurcation models. Provisional SB stenting was replicated including post-dilation after main branch stenting. Two bifurcation angles (45°, 70°) and four plaque types (fully lipid, fully fibrous, lipid with half and fully calcified ring distal to the carina) were tested. Two post-dilation balloons of different lengths (15 mm and 9 mm) were also investigated. Provisional stenting caused an ovalisation of the SB ostium (i.e., increase of ellipticity from 0.27 to 0.58±0.21, p

The automated extraction of anatomical reference landmarks in the femoral volume may improve speed, precision, and accuracy of surgical procedures, such as total hip arthroplasty. These landmarks are often hard to achieve, even via surgical incision. In addition, it provides a presurgical guidance for prosthesis sizing and placement. This study presents an automated workflow for femoral orientation and landmark extraction from a 3D surface mesh. The extraction of parameters such as the femoral neck axis, the femoral middle diaphysis axis, both trochanters and the center of the femoral head will allow the surgeon to establish the correct position of bony cuts to restore leg length and femoral offset. The definition of the medullary canal endosteal wall is used to position the prosthesis' stem. Furthermore, prosthesis alignment and sizing methods were implemented to provide the surgeon with presurgical information about performance of each of the patient-specific femur-implant couplings. The workflow considers different commercially available hip stems and has the potential to help the preoperative planning of a total hip arthroplasty in an accurate, repeatable, and reliable way. The positional and orientation errors are significantly reduced, and therefore, the risk of implant failure and subsequent revision surgery are also reduced.

Femur segmentation can be an important tool in orthopedic surgical planning. However, in order to overcome the need of an experienced user with extensive knowledge on the techniques, segmentation should be fully automatic. In this paper a new fully automatic femur segmentation method for CT images is presented. This method is also able to define automatically the medullary canal and performs well even in low resolution CT scans. Fully automatic femoral segmentation was performed adapting a template mesh of the femoral volume to medical images. In order to achieve this, an adaptation of the active shape model (ASM) technique based on the statistical shape model (SSM) and local appearance model (LAM) of the femur with a novel initialization method was used, to drive the template mesh deformation in order to fit the in-image femoral shape in a time effective approach. With the proposed method a 98% convergence rate was achieved. For high resolution CT images group the average error is less than 1mm. For the low resolution image group the results are also accurate and the average error is less than 1.5mm. The proposed segmentation pipeline is accurate, robust and completely user free. The method is robust to patient orientation, image artifacts and poorly defined edges. The results excelled even in CT images with a significant slice thickness, i.e., above 5mm. Medullary canal segmentation increases the geometric information that can be used in orthopedic surgical planning or in finite element analysis.

SUMMARY Technological advances are often inspired by nature, considering that engineering is frequently faced by the same challenges as organisms in nature. One such interesting challenge is creating a structure that is at the same time stiff in a certain direction, yet flexible in another. The seahorse tail combines both radial stiffness and bending flexibility in a particularly elegant way: even though the tail is covered in a protective armour, it still shows sufficient flexibility to fully function as a prehensile organ. We therefore study the complex mechanics and dynamics of the musculoskeletal system of the seahorse tail from an engineering point of view. The seahorse tail derives its combination of flexibility and resilience from a chain of articulating skeletal segments. A versatile dynamic model of those segments was constructed, on the basis of automatic recognition of joint positions and muscle attachments. Both muscle structures that are thought to be responsible for ventral and ventral–lateral tail bending, namely the median ventral muscles and the hypaxial myomere muscles, were included in the model. Simulations on the model consist mainly of dynamic multi-body simulations. The results show that the sequential structure of uniformly shaped bony segments can remain flexible because of gliding joints that connect the corners of the segments. Radial stiffness on the other hand is obtained through the support that the central vertebra provides to the tail plating. Such insights could help in designing biomedical instruments that specifically require both high bending flexibility and radial stiffness (e.g. flexible stents and steerable catheters).Copyright © 2012 John Wiley & Sons, Ltd.

There is a growing interest in virtual tools to assist clinicians in evaluating different procedures and devices for endovascular treatment. In the present study we use finite element analysis to investigate the influence of stent design and vessel geometry for stent assisted coiling of intracranial aneurysms. Nine virtual stenting procedures were performed: three nitinol stent designs ((i) an open cell stent resembling the Neuroform, (ii) a generic stiff and (iii) a more flexible closed cell design), were deployed in three patient-specific cerebral aneurysmatic vessels. We investigated the percentage of strut area covering the aneurysm neck, the straightening induced on the cerebrovasculature by the stent placement (quantified by the reduction in tortuosity), and stent apposition to the wall (quantified as the percentage of struts within 0.2mm of the vessel). The results suggest that the open cell design better covers the aneurysm neck (11.0±1.1%) compared to both the stiff (7.8±1.6%) and flexible (8.7±1.6%) closed cell stents, and induces less straightening of the vessel (-5.1±1.6% vs. -42.9±9.8% and -26.9±11.9% ). The open cell design has, however, less struts apposing well to the vessel wall (56.0±6.4%) compared to the flexible (73.4±4.6%) and stiff (70.4±5.1%) closed cell design. With the presented study, we hope to contribute to and improve aneurysm treatment, using a novel patient specific environment as a possible pre-operative tool to evaluate mechanical stent behavior in different vascular geometries.

In the original publication of the article, Tables 2 and 3 were published with error. The correct tables are provided below (Tables 2, 3). The original version of the article has also been corrected.

SUMMARY The automated extraction of anatomical reference parameters may improve speed, precision and accuracy of surgical procedures. In this study, an automated method for extracting the femoral anatomical axis (FAA) from a 3D surface mesh, based on geometrical entity fitting, is presented. This was applied to conventional total knee arthroplasty, which uses an intramedullary rod (FIR) to orient the femoral prosthesis with respect to the FAA. The orientation and entry point of a FIR with a length of 200 mm are automatically determined from the FAA, as it has been shown that errors in these parameters may lead to malalignment of the mechanical axis. Moreover, the effect of partially scanning the leg was investigated by creating reduced femur models and comparing the results with the full models. Precise measurements are obtained for 50 models by using a central and two outer parts, with lengths of 20 and 120 mm, which correspond to 58% of the mean femoral length. The deviations were less than 2 mm for the FAA, 2.8 mm for the FAA endpoints and 0.7°and 1.3 mm for the FIR orientation and entry point. The computer-based techniques might eventually be used for preoperative planning of total knee arthroplasty. Copyright © 2011 John Wiley & Sons, Ltd.

Aims: The aim of this study was to compare the stent strut apposition and stent induced vessel wall stresses of currently used coronary stent designs. This may help to better understand their clinical performance and provide the insights necessary for further optimisation. Methods and results: We compared the stent strut apposition of six different stent designs when deployed (at 12 atm) in an idealised stenosed vessel using a novel approach based on finite element simulations. Additional insights into the mechanical behaviour of the investigated stents were obtained by virtually quantifying the stent induced vessel wall stresses. For the investigated stenosed vessel model, the percentage of malapposed struts (distance to wall > 10 mu m) ranged between 9% (Integrity stent) and 43% (Promus Element stent). The largest strut-artery distances were observed at the plaque shoulders. The 95 percentile of the axial stress within the intima ranges from 32 (Promus Element stent) to 83 kPa (Liberte stent). Stress peaks were mainly located at the inner curvatures of the vessel model and at the stent ends. Conclusions: For the investigated case, considerable differences were observed between the studied stent platforms in terms of stent strut apposition and stent induced vessel wall stresses. These differences in mechanical behaviour may help to explain clinical observations.

To quantitatively evaluate the impact of carotid stent cell design on vessel scaffolding by using patient-specific finite element analysis of carotid artery stenting (CAS).The study was organized in 2 parts: (1) validation of a patient-specific finite element analysis of CAS and (2) evaluation of vessel scaffolding. Micro-computed tomography (CT) images of an open-cell stent deployed in a patient-specific silicone mock artery were compared with the corresponding finite element analysis results. This simulation was repeated for the closed-cell counterpart. In the second part, the stent strut distribution, as reflected by the inter-strut angles, was evaluated for both cell types in different vessel cross sections as a measure of scaffolding.The results of the patient-specific finite element analysis of CAS matched well with experimental stent deployment both qualitatively and quantitatively, demonstrating the reliability of the numerical approach. The measured inter-strut angles suggested that the closed-cell design provided superior vessel scaffolding compared to the open-cell counterpart. However, the full strut interconnection of the closed-cell design reduced the stent's ability to accommodate to the irregular eccentric profile of the vessel cross section, leading to a gap between the stent surface and the vessel wall.Even though this study was limited to a single stent design and one vascular anatomy, the study confirmed the capability of dedicated computer simulations to predict differences in scaffolding by open- and closed-cell carotid artery stents. These simulations have the potential to be used in the design of novel carotid stents or for procedure planning.

The introduction of drug-eluting stents (DES) has reduced the occurrence of restenosis in coronary arteries. However, restenosis remains a problem in stented coronary bifurcations. This study investigates and compares three different second generation DESs when being implanted in the curved main branch of a coronary bifurcation with the aim of providing better insights into the related changes of the mechanical environment. The 3D bifurcation model is based on patient-specific angiographic data that accurately reproduce the in vivo curvatures of the vessel segments. The layered structure of the arterial wall and its anisotropic mechanical behavior are taken into account by applying a novel algorithm to define the fiber orientations. An innovative simulation strategy considering the insertion of a folded balloon catheter over a guide wire is proposed in order to position the stents within the curved vessel. Straightening occurs after implantation of all stents investigated. The resulting distributions of the wall stresses are strongly dependent on the stent design. Using a parametric modeling approach, two design modifications, which reduce the predicted maximum values of the wall stress, are proposed and analyzed.

The widespread acceptance of carotid artery stenting (CAS) to treat carotid artery stenosis and its effectiveness compared with surgical counterpart, carotid endarterectomy (CEA), is still a matter of debate. Transient or permanent neurological deficits may develop in patients undergoing CAS due to distal embolization or hemodynamic changes. Design, development, and usage of embolic protection devices (EPDs), such as embolic protection filters, appear to have a significant impact on the success of CAS. Unfortunately, some drawbacks, such as filtering failure, inability to cross tortuous high-grade stenoses, malpositioning and vessel injury, still remain and require design improvement. Currently, many different designs of such devices are available on the rapidly growing dedicated market. In spite of such a growing commercial interest, there is a significant need for design tools as well as for careful engineering investigations and design analyses of such nitinol devices. The present study aims to investigate the embolic protection filter design by finite element analysis. We first developed a parametrical computer-aided design model of an embolic filter based on micro-CT scans of the Angioguard™ XP (Cordis Endovascular, FL) EPD by means of the open source pyFormex software. Subsequently, we used the finite element method to simulate the deployment of the nitinol filter as it exits the delivery sheath. Comparison of the simulations with micro-CT images of the real device exiting the catheter showed excellent correspondence with our simulations. Finally, we evaluated circumferential basket-vessel wall apposition of a 4 mm size filter in a straight vessel of different sizes and shape. We conclude that the proposed methodology offers a useful tool to evaluate and to compare current or new designs of EPDs. Further simulations will investigate vessel wall apposition in a realistic tortuous anatomy.

Stent implantation has become a widely accepted endovascular intervention for the treatment of stenosed arteries. This minimally invasive technique has shown excellent results in unbranched arteries. However, stenting bifurcation lesions remains a challenge in coronary intervention as it is associated with a lower success rate. Many different techniques have been proposed in medical practice but all the suggested methodologies have specific limitations. Numerical simulations may help to understand and eliminate the shortcomings of current clinical techniques and devices. In this study, one of the currently applied techniques is analysed which involves the implantation of a stent in the main branch, followed by subsequent inflation of a balloon through the side of the stent. This improves the side branch patency and provides access to the side branch for later stent implantations. The impact of using different balloon sizes and stent designs was investigated. The stent cell through which the balloon is inflated increases considerably and as intuitively expected, using a larger balloon results in a larger opening. Furthermore, it was observed that this procedure may compromise the downstream main branch lumen. These observations correspond well with previously reported results, which were based on in vitro studies. The added value of the proposed numerical model is the ability to study many different techniques/stents, without the need for various expensive stent samples.

At present, the deployment of self-expandable braided stents has become a common and widely used minimally invasive treatment for stenotic lesions in the cardiovascular, gastrointestinal and respiratory system. To improve these revascularization procedures (e.g. increase the positioning accuracy) the optimal strategy lies in the further development of the stent design. In the context of optimizing braided stent designs, computational models can provide an excellent research tool complementary to analytical models. In this study, a finite element based modelling strategy is proposed to investigate and optimize the mechanics of braided stents. First a geometrical and finite element model of a braided Urolume endoprosthesis was built with the open source pyFormex design tool. The results of the reference simulation of the Urolume stent are in close agreement with both analytical and experimental data. Subsequently, a simplex-based design optimization algorithm automatically adjusts the reference Urolume geometry to facilitate precise positioning by reducing the foreshortening with 20% while maintaining the radial stiffness. Therefore, the proposed modelling strategy appears to be a promising optimization methodology in braided stent design.

Recent numerical studies of abdominal aortic aneurysm (AAA) suggest that intraluminal thrombus (ILT) may reduce the stress loading on the aneurysmal wall. Detailed fluid structure interaction (FSI) in the presence and absence of ILT may help predict AAA rupture risk better. Two patients, with varied AAA geometries and ILT structures, were studied and compared in detail. The patient specific 3D geometries were reconstructed from CT scans, and uncoupled FSI approach was applied. Complex flow trajectories within the AAA lumen indicated a viable mechanism for the formation and growth of the ILT. The resulting magnitude and location of the peak wall stresses was dependent on the shape of the AAA, and the ILT appeared to reduce wall stresses for both patients. Accordingly, the inclusion of ILT in stress analysis of AAA is of importance and would likely increase the accuracy of predicting AAA risk of rupture.

Aims: The size of stent cells is an important design parameter influencing the resulting wall coverage and strut positioning of several bifurcation stenting techniques. Therefore, we report accurate geometrical information on stent cell size of five different stents with the key purpose to assist with stent selection for bifurcation lesions. Methods and results: We developed an innovative technique to assess cell size with high accuracy based on micro-CT images. In addition, the size of the ostium was calculated for several idealised bifurcations with a cylindrical main and side branch. The cell circumferences of the investigated stents vary substantially, with values between 9.5 and 19.8 mm (or an equivalent maximal cell diameter between 3.0 and 6.3 mm). Comparison of these cell circumferences with the calculated ostium circumferences shows which stents should preferably be used for which bifurcations, as these stents have cells that can be sufficiently enlarged by dilating through the side. Conclusions: The cell sizes of the investigated stents differ considerably. This should be taken into account when applying a particular bifurcation stenting technique. The risk on limited main or side branch patency due to obstructing stent struts can be minimised by using the reported data for stent selection.

Aims: Our aim was to validate patient-specific software integrating baseline anatomy and biomechanical properties of both the aortic root and valve for the prediction of valve morphology and aortic leaflet calcium displacement after TAVI. Methods and results: Finite element computer modelling was performed in 39 patients treated with a Medtronic CoreValve System (MCS; n=33) or an Edwards SAPIEN XT (ESV; n=6). Quantitative axial frame morphology at inflow (MCS, ESV) and nadir, coaptation and commissures (MCS) was compared between multislice computed tomography (MSCT) post TAVI and a computer model as well as displacement of the aortic leaflet calcifications, quantified by the distance between the coronary ostium and the closest calcium nodule. Bland-Altman analysis revealed a strong correlation between the observed (MSCT) and predicted frame dimensions, although small differences were detected for, e.g., Dmin at the inflow (mean +/- SD MSCT vs. model: 21.6 +/- 2.4 mm vs. 22.0 +/- 2.4 mm; difference +/- SD: -0.4 +/- 1.3 mm, p

Clinical studies have demonstrated the efficacy of stent supported coiling for intra-cranial aneurysm treatment. Despite encouraging outcomes, some matters are yet to be addressed. In particular closed stent designs are influenced by the delivery technique and may suffer from under-expansion, with the typical effect of "hugging" the inner curvature of the vessel which seems related to adverse events. In this study we propose a novel finite element (FE) environment to study potential failure able to reproduce the microcatheter "pull-back" delivery technique. We first verified our procedure with published in vitro data and then replicated the intervention on one patient treated with a 4.5 × 22 mm Enterprise microstent (Codman Neurovascular; Raynham MA, USA). Results showed good agreement with the in vitro test, catching both size and location of the malapposed area. A simulation of a 28 mm stent in the same geometry highlighted the impact of the delivery technique, which leads to larger area of malapposition. The patient specific simulation matched the global stent configuration and zones prone to malapposition shown on the clinical images with difference in tortuosity between actual and virtual treatment around 2.3%. We conclude that the presented FE strategy provides an accurate description of the stent mechanics and, after further in vivo validation and optimization, will be a tool to aid clinicians to anticipate the acute procedural outcome avoiding poor initial results.

Outcome of transcatheter aortic valve replacement (TAVR) depends on a combination of patient-, procedure-, and operator-related variables. Specific device–host-related interactions may also be involved and may result in, for instance, incomplete and/or nonuniform frame expansion that in turn may

In Western countries, cardiovascular disease is the most common cause of death, often related to atherosclerosis which can lead to a narrowing of the arteries. To restore perfusion of downstream tissues, an intravascular stent (i.e. a small tube-like structure) can be deployed in the obstructed vessel. The vast majority of stents are balloon expandable and crimped on a folded balloon to obtain a low profile for deliverability and lesion access. Several studies have exploited the finite element method to gain insight in their mechanical behaviour or to study the vascular reaction to stent deployment. However, to date – to the best of our knowledge – none of them include the balloon itself in its actual folded shape. Furthermore, literature on the effect of the crimping process on the expansion behaviour of the stent is even scarcer. Our numerical results - accounting for the presence of the balloon in its actual folded shape - correspond very well with data provided by the manufacturer and consequently our approach could be the basis for new realistic computational models of angioplasty procedures. The plastic deformation, prior to the stent expansion and induced by the crimping procedure, has a minor influence on the overall expansion behaviour of the stent but nevertheless influences the maximum von Mises stress and nominal strain. The maximum von Mises stress drops from 440 N/mm² to 426 N/mm² and the maximum nominal strain value lowers from 0.23 to 0.22 at the end of the expansion phase when neglecting the presence of the residual stresses. Depending on the context in which to use the developed mathematical models, the crimping phase can be discarded from the simulations in order to speed up the analyses.

A common treatment to restore normal blood flow in an obstructed artery is the deployment of a stent (i.e. small tube-like structure). The vast majority of stents are crimped on a folded balloon and laser cut from 316L stainless steel tubes. Although, several numerical studies (exploiting the Finite Element Method) are dedicated to the mechanical behaviour of balloon expandable stents, there seems to be no consensus regarding the mechanical properties to describe the inelastic material behaviour of SS316L. Moreover, as the typical dimensions of stent struts (e.g. 100 μm for coronary stents) are of a similar order of magnitude as the average grain size in stainless steel (i.e. 25 μm), continuum approaches relying on macroscopic material properties may be questionable. In addition, an experimental study on stainless steel stent strut specimens showed a size-dependency of the failure strain. In this study the impact of the magnitude of the yield stress on the stent expansion behavior is examined. An increase in the yield stress (from 205 N/mm² to 375 N/mm²) results in an increase of the pressure (from about 0.3 N/mm² to approximately 0.4 N/mm²) which the clinician needs to exert for the balloon to unfold and to reach its cylindrical expanded shape. Furthermore, the effect of the size dependency behavior of the material is studied by monitoring the nominal strain during stent expansion. The maximum value of the nominal strain in the expanded stent (e.g. εn = 23 %) does not exceed the critical value of the failure strain, (i.e. εn = 33 %), moreover the critical values are nowhere exceeded in the whole stent during the expansion. Our numerical results - accounting for the presence of the balloon in its actual folded shape - correspond very well with pressure/diameter data supplied by the manufacturer. Consequently, this study shows that the free expansion of new generation balloon-expandable stents can be studied accurately with computational analysis based on the Finite Element Method (FEM) and relying on macroscopic material properties. In this context, there is no need to implement a size-based constitutive material model, but before accepting the results of the study, one should check in any case the maximum strain against the limit as shown above.

Background For many years, researchers have attempted to describe shoulder motions by using different mathematical methods. The aim of this study was to describe a procedure to quantify clavicular motion. Methods The procedure proposed for the kinematic analysis consists of 4 main processes: 3 transcortical pins in the clavicle, motion capture, obtaining 3-dimensional bone models, and data processing. Results Clavicular motion by abduction (30° to 150°) and flexion (55° to 165°) were characterized by an increment of retraction of 27° to 33°, elevation of 25° to 28°, and posterior rotation of 14° to 15°, respectively. In circumduction, clavicular movement described an ellipse, which was reflected by retraction and elevation. Kinematic analysis shows that the articular surfaces move by simultaneously rolling and sliding on the convex surface of the sternum for the 3 movements of abduction, flexion, and circumduction. Conclusion The use of 3 body landmarks in the clavicle and the direct measurement of bone allowed description of the osteokinematic and arthrokinematic movement of the clavicle.

The feasibility of shear wave elastography (SWE) in arteries for cardiovascular risk assessment remains to be investigated as the artery's thin wall and intricate material properties induce complex shear wave (SW) propagation phenomena. To better understand the SW physics in bounded media, we proposed an in vitro validated finite element model capable of simulating SW propagation, with full flexibility at the level of the tissue's geometry, material properties, and acoustic radiation force. This computer model was presented in a relatively basic set-up, a homogeneous slab of gelatin-agar material (4.35 mm thick), allowing validation of the numerical settings according to actual SWE measurements. The resulting tissue velocity waveforms and SW propagation speed matched well with the measurement: 4.46 m/s (simulation) versus 4.63 ± 0.07 m/s (experiment). Further, we identified the impact of geometrical and material parameters on the SW propagation characteristics. As expected, phantom thickness was a determining factor of dispersion. Adding viscoelasticity to the model augmented the estimated wave speed to 4.58 m/s, an even better match with the experimental determined value. This study demonstrated that finite element modeling can be a powerful tool to gain insight into SWE mechanics and will in future work be advanced to more clinically relevant settings.

In Western countries, cardiovascular disease is the most common cause of death, often related to atherosclerosis. This paper offers a brief introduction into some aspects of this disease and its treatment, where the use of stents is gaining increasing importance. Stents are supporting – mostly metal – tubular mesh structures which are opened in an obstructed artery in order to reopen it, and to offer radial strength to prevent elastic recoil of the dilated vessel. In addition to a variety of experimental tests to study the behavior of (new) stent designs, advanced numerical models (e.g. Finite Element Models) may offer interesting insights in the mechanical behavior of stents and will undoubtedly influence the design of future generation stents. A brief literature review on numerical studies dealing with the mechanical behavior of stents is presented. Subsequently, the finite element method is exploited to investigate and compare different designs of a "first generation" Palmaz Schatz stent in order to reduce the dogboning (i.e. ends of stent open first during expansion) to a minimum. Our computational models (Abaqus [1]) are described in terms of geometry, constitutive material models, numerical aspects and output quantities. Altering the original symmetric stent design to asymmetric designs decreased the dogboning from 27.24% to less than 10% for the vast majority of the studied asymmetric designs. For one particular configuration, the dogboning effect vanished completely. For this reason, taking asymmetry into account in the design of stents seems very promising, at least from the perspective of dogboning. However, as the dogboning only takes into account the radii (R) at the central and distal part of the stent, nothing can be concluded concerning the uniformity of the complete stent expansion. The mean value (R_{m}) and the root mean square (R_{RMS}) of radii (differences) of the stent at the end of the loading phase (P=0.7 N/mm^{2}) are much better parameters to give a clear indication of the uniformity of the expanded stent's shape. Although the model is suitable to study basic aspects of stent deployment, further research is necessary, especially accounting for newer generation stent geometries and more realistic balloon-stent interaction.

Recent research has revealed that angiotensin II-induced abdominal aortic aneurysm in mice can be related to medial ruptures occurring in the vicinity of abdominal side branches. Nevertheless a thorough understanding of the biomechanics near abdominal side branches in mice is lacking. In the current work we present a mouse-specific fluid-structure interaction (FSI) model of the abdominal aorta in ApoE(-/-) mice that incorporates in vivo stresses. The aortic geometry was based on contrast-enhanced in vivo micro-CT images, while aortic flow boundary conditions and material model parameters were based on in vivo high-frequency ultrasound. Flow waveforms predicted by FSI simulations corresponded better to in vivo measurements than those from CFD simulations. Peak-systolic principal stresses at the inner and outer aortic wall were locally increased caudal to the celiac and left lateral to the celiac and mesenteric arteries. Interestingly, these were also the locations at which a tear in the tunica media had been observed in previous work on angiotensin II-infused mice. Our preliminary results therefore suggest that local biomechanics play an important role in the pathophysiology of branch-related ruptures in angiotensin-II infused mice. More elaborate follow-up research is needed to demonstrate the role of biomechanics and mechanobiology in a longitudinal setting.

La descripción del comportamiento mecánico de tejidos duros mediante el empleo de modelos discretos pasa por diferentes etapas de análisis, que van desde el procesamiento digital de la imagen hasta la especificación de las propiedades físicas del tejido al modelo discreto. Para lograr un buen resultado es esencial la descomposición de esos modelos en sus partes constitutivas. En este trabajo se discute un método para la descripción geométrica de los huesos del pie a partir de una secuencia de imágenes (cortes) de tomografía computarizada (TC). La investigación propone la combinación de la umbralización global y de la adaptativa para la determinación del dominio geométrico de los huesos en cada corte, así como el análisis de las relaciones espaciales entre contornos en planos consecutivos a fin de obtener las isosuperficies de los huesos. Se propone un algoritmo semiautomático basado en 4 etapas: la lectura de los cortes de imágenes de TC; la determinación de los contornos que definen el tejido óseo presentes en cada corte; la formación de los volúmenes a través del agrupamiento de los contornos cuya relación espacial cumple un criterio determinado; y la eliminación de las isosuperficies no válidas. Como resultado se obtiene la definición de la mayoría de los huesos del pie cuyo rango de valores en la escala de Hounsfield es [–1.000; 1.383]. The description of the mechanical behavior of hard tissues by means of discrete models goes through various stages of analysis, which range from digital image processing to the specification of tissues physical properties to the discrete model. To achieve good results it is essential to decompose these models into their constituent parts. In this paper we discuss a method for geometrical description of foot bones from a sequence of computed tomography (CT) images. This research proposes a combination between global and adaptive thresholdings to determine the geometric domain of bones in each slice and the analysis of the spatial relationships between contours in consecutive planes in order to obtain bones’ isosurfaces. The algorithm proposed is based on 4 stages: the reading of computed tomography (CT) images; the determination of the contours that define the bone tissue present on each slice; the grouping of contours whose relationship meet a given criteria; the elimination of non-valid volumes. As a result, it is possible to obtain the geometrical domain of a great number of foot bones whose range in the Hounsfield is [–1000; 1383].

Bioresorbable stents represent a promising technological development within the field of cardiovascular angioplasty because of their ability to avoid long-term side effects of conventional stents such as in-stent restenosis, late stent thrombosis and fatigue induced strut fracture. Finite element simulations have proven to present a useful research tool for the design and mechanical analysis of stents. However, biodegradable stents pose new challenges because of their transitional mechanical behaviour. For polymeric biodegradable stents, viscoplastic effects have to be accounted for. This paper presents a method to analyse the mechanical behaviour of polymeric bioresorbable stents using an implicit finite-element solver. As an example, we investigate the mechanical behaviour of a commercially available bioresorbable stent. We examine how, due to the visco-elastic properties of the stent material, the balloon deployment rate influences the mechanical integrity of the stent.

The study aimed to evaluate the adequacy and feasibility of the single string bifurcation stenting technique.Double-stent techniques may be required for complex bifurcations. Currently applied methods all have their morphological or structural limitations with respect to wall coverage, multiple strut layers, and apposition rate.Single string is a novel method in which, first, the side branch (SB) stent is deployed with a single stent cell protruding into the main branch (MB). Second, the MB stent is deployed across this protruding stent cell. The procedure is completed by final kissing balloon dilation. The single string technique was first tested in vitro (n = 20) and next applied in patients (n = 11) with complex bifurcation stenoses.All procedures were performed successfully, crossing a single stent cell in 100%. Procedure duration was 23.0 ± 7.9 min, and the fluoroscopy time was 9.4 ± 3.5 min. The results were evaluated by optical coherence tomography, showing fully apposed struts in 83.0 ± 9.2% in the bifurcation area. Residual area obstruction in the MB was 6.4 ± 5.6% and 25.0 ± 16.9% in the SB, as evaluated by micro computed tomography. All the human cases were performed successfully with excellent angiographic results: the residual area stenosis was 27 ± 8% and 29 ± 10% in the MB and in the SB, respectively, by 3-dimensional quantitative coronary angiography. No relevant periprocedural enzyme increase was observed. During follow-up (6 ± 4 months), no adverse clinical events (death, myocardial infarction, target vessel revascularization) were noted.The single string technique for complex bifurcation dilation was shown to be adequate in vitro and feasible in humans, with favorable results in terms of stent overlap, malapposition rate, and low residual obstruction in both the MB and SB.

Carotid artery stenting is emerging as an alternative technique to surgery for the treatment of symptomatic severe carotid stenosis. Clinical and experimental evidence demonstrates that both plaque morphology and biomechanical changes due to the device implantation can be possible causes of an unsuccessful treatment. In order to gain further insights of the endovascular intervention, a virtual environment based on structural finite element simulations was built to emulate the stenting procedure on generalized atherosclerotic carotid geometries which included a damage model to quantify the injury of the vessel. Five possible lesion scenarios were simulated by changing both material properties and vascular geometrical features to cover both presumed vulnerable and stable plaques. The results were analyzed with respect to lumen gain and wall stresses which are potentially related to the failure of the procedure according to previous studies. Our findings show that an elliptic lumen shape and a thinner fibrous cap with an underlying lipid pool result in higher stenosis reduction, while large calcifications and fibrotic tissue are more prone to recoil. The shielding effect of a thicker fibrous cap helps to reduce local compressive stresses in the soft plaque. The presence of a soft plaque reduces the damage in the healthy vascular structures. Contrarily, the presence of hard plaque promotes less damage volume in the fibrous cap and reduces stress peaks in this region, but they seem to increase stresses in the media-intima layer. Finally the reliability of the achieved results was put into clinical perspective.

An abdominal aortic aneurysm (AAA) of the aorta is a local widening of the aorta in a region between the renal arteries and the aortic bifurcation. The disease impacts the structural integrity of the AAA wall, weakening the tissue and predisposing it to rupture. Preventive treatment of the disease is often performed minimally invasive with endovascular repair by stent graft deployment, as an alternative to open surgical repair. During endovascular aneurysm repair, a metallic stent, covered with a polymer membrane is first crimped and mounted onto the delivery system and inserted through the iliac artery. It is advanced to the AAA region, and expanded to cover the weakened, ballooning aorta. The technique has excellent clinical outcome, yet it is still associated with long term problems such as migration, a downward displacement of the device, and endoleakage, with blood reentering and pressurizing the aneurismal sack.Copyright © 2013 by ASME