We report a study of the role of hemodynamic shear stress in the remodeling and failure of a peripheral artery bypass graft. Three separate scans of a femoral to popliteal above-knee bypass graft were taken over the course of a 16 month period following a revision of the graft. The morphology of the lumen is reconstructed from data obtained by a custom 3D ultrasound system. Numerical simulations are performed with the patient-specific geometries and physiologically realistic flow rates. The ultrasound reconstructions reveal two significant areas of remodeling: a stenosis with over 85% reduction in area, which ultimately caused graft failure, and a poststenotic dilatation or widening of the lumen. Likewise, the simulations reveal a complicated hemodynamic environment within the graft. Preliminary comparisons with in vivo velocimetry also showed qualitative agreement with the flow dynamics observed in the simulations. Two distinct flow features are discerned and are hypothesized to directly initiate the observed in vivo remodeling. First, a flow separation occurs at the stenosis. A low shear recirculation region subsequently develops distal to the stenosis. The low shear region is thought to be conducive to smooth muscle cell proliferation and intimal growth. A poststenotic jet issues from the stenosis and subsequently impinges onto the lumen wall. The lumen dilation is thought to be a direct result of the high shear stress and high frequency pressure fluctuations associated with the jet impingement.

1.
Conte
,
M. S.
, 2006, “
Results of Prevent III: A Multicenter, Randomized Trial of Edifolidge for the Prevention of Vein Graft Failure in Lower Extremity Bypass Surgery
,”
J. Vasc. Surg.
0741-5214,
43
(
4
), pp.
742
751
.
2.
Goodney
,
P. P.
,
Beck
,
A. W.
,
Nagle
,
J.
,
Welch
,
H. G.
, and
Zwolak
,
R. M.
, 2009, “
National Trends in Lower Extremity Bypass Surgery, Endovascular Interventions, and Major Amputations
,”
J. Vasc. Surg.
0741-5214,
50
(
1
), pp.
54
60
.
3.
Mills
,
J. L.
,
Bandyk
,
D. F.
,
Gahtan
,
V.
, and
Esses
,
G. E.
, 1995, “
The Origin of Infrainguinal Vein Graft Stenosis: A Prospective Study Based on Duplex Surveillance
,”
J. Vasc. Surg.
0741-5214,
21
(
1
), pp.
16
25
.
4.
Watson
,
H. R.
,
Buth
,
J.
,
Schroeder
,
T. V.
,
Simms
,
M. H.
, and
Horrocks
,
M.
, 2000, “
Incidence of Stenoses in Femorodistal Bypass Vein Grafts in a Mulicentre Study
,”
Eur. J. Vasc. Endovasc Surg.
1078-5884,
20
, pp.
67
71
.
5.
Owens
,
C. D.
,
Rybicki
,
F. J.
,
Wake
,
N.
,
Schanzer
,
A.
,
Mitsouras
,
D.
,
Gerhard-Herman
,
M. D.
, and
Conte
,
M. S.
, 2008, “
Early Remodeling of Lower Extremity Vein Grafts: Inflammation Influences Biomechanical Adaptation
,”
J. Vasc. Surg.
0741-5214,
47
(
6
), pp.
1235
1242
.
6.
Fillinger
,
M. F.
,
Cronenwett
,
J. L.
,
Besso
,
S.
,
Walsh
,
D. B.
, and
Zwolak
,
R. M.
, 1994, “
Vein Adaption to the Hemodynamic Environment of Infrainguinal Grafts
,”
J. Vasc. Surg.
0741-5214,
19
, pp.
970
978
.
7.
Owens
,
C. D.
,
Wake
,
N.
,
Jacot
,
J. G.
,
Gerhard-Herman
,
M.
,
Gaccionce
,
P.
,
Belkin
,
M.
,
Creager
,
M. A.
, and
Conte
,
M. S.
, 2006, “
Early Biomechanical Changes in Lower Exremity Vein Grafts—Distinct Temporal Phases of Remodeling and Wall Stiffness
,”
J. Vasc. Surg.
0741-5214,
44
(
4
), pp.
740
746
.
8.
Galt
,
S. W.
,
Zwolak
,
R. M.
,
Wagner
,
R. J.
, and
Gillbertson
,
J. J.
, 1993, “
Differential Response of Arteries and Vein Grafts to Blood Flow Reduction
,”
J. Vasc. Surg.
0741-5214,
17
(
3
), pp.
563
570
.
9.
Dobrin
,
P. B.
, 1995, “
Mechanical Factors Associated With the Development of Intimal and Medial Thickening in Vein Grafts Subjected to Arterial Pressure
,”
Hypertension
0194-911X,
26
, pp.
38
43
.
10.
Lemson
,
M. S.
,
Tordoir
,
J. H. M.
,
Daemen
,
M. J. A. P.
, and
Kitslaar
,
P. J. E. H. M.
, 2000, “
Intimal Hyperplasia in Vascular Grafts
,”
Eur. J. Vasc. Endovasc Surg.
1078-5884,
19
, pp.
336
350
.
11.
Kohler
,
T. R.
,
Kirkman
,
T. R.
,
Kraiss
,
L. W.
,
Zierler
,
B. K.
, and
Clowes
,
A. W.
, 1991, “
Increased Blood Flow Inhibits Neointimal Hyperplasia in Endothelialized Vascular Grafts
,”
Circ. Res.
0009-7330,
69
, pp.
1557
1565
.
12.
Bassiouny
,
H. S.
,
White
,
S.
,
Glagov
,
S.
,
Choi
,
E.
,
Giddens
,
D. P.
, and
Zarins
,
C. K.
, 1992, “
Anastomotic Intimal Hyperplasia: Mechanical Injury or Flow Induced
,”
J. Vasc. Surg.
0741-5214,
15
(
4
), pp.
708
717
.
13.
Meyerson
,
S. L.
,
Skelly
,
C. L.
,
Curi
,
M. A.
,
Shakur
,
U. M.
,
Vosicky
,
J. E.
,
Glagov
,
S.
,
Christen
,
T.
,
Gabbiani
,
G.
, and
Schwartz
,
L. B.
, 2001, “
The Effects of Extremely Low Shear Stress on Cellular Proliferation and Neointimal Thickening in the Failing Bypass Graft
,”
J. Vasc. Surg.
0741-5214,
34
(
1
), pp.
90
97
.
14.
Jiang
,
Z.
,
Wu
,
L.
,
Miller
,
B. L.
,
Goldman
,
D. R.
,
Fernandez
,
C. M.
,
Abouhamze
,
Z. S.
,
Ozaki
,
C. K.
, and
Berceli
,
S. A.
, 2003, “
A Novel Vein Graft Model: Adaption to Differential Flow Environments
,”
Am. J. Physiol. Heart Circ. Physiol.
0363-6135,
286
, pp.
240
245
.
15.
DePaola
,
N.
Gimbrone
,
M. A.
, Jr.
,
Davies
,
P. F.
, and
Dewey
,
C. F.
, Jr.
, 1992, “
Vascular Endothelium Responds to Fluid Shear Stress Gradients
,”
Arterioscler., Thromb. Vasc. Biol.
,
12
, pp.
1254
1257
.
16.
White
,
C. R.
,
Haidekker
,
M.
,
Bao
,
X.
, and
Frangos
,
J. A.
, 2001, “
Temporal Gradients in Shear, But Not Spatial Gradients, Stimulate Endothelial Cell Proliferation
,”
Circulation
0009-7322,
103
, pp.
2508
2513
.
17.
Carroll
,
G. T.
,
McGloughlin
,
T. M.
,
O’Keefee
,
L. M.
, and
Callanan
,
A.
, 2009, “
Realistic Temporal Variations of Shear Stress Modulate mmp-2 and mcp-1 Expression in Arteriovenous Vascular Grafts
,”
Cell Mol Bioengr
,
2
(
4
), pp.
591
605
.
18.
Owens
,
C. D.
, 2010, “
Adaptive Changes in Autogenous Vein Grafts for Arterial Reconstruction: Clinical Implications
,”
J. Vasc. Surg.
0741-5214,
51
(
3
), pp.
736
746
.
19.
Leotta
,
D. F.
,
Primozich
,
J. F.
,
Beach
,
K. W.
,
Bergelin
,
R. O.
,
Zierler
,
R. E.
, and
Strandness
,
D. E.
, Jr.
, 2003, “
Remodeling in Peripheral Vein Graft Revisions: Serial Study With Three-Dimensional Ultrasound Imaging
,”
J. Vasc. Surg.
0741-5214,
37
(
4
), pp.
798
807
.
20.
Loth
,
F.
,
Fischer
,
P. F.
, and
Bassiouny
,
H. S.
, 2008, “
Blood Flow in End-to-Side Anastomoses
,”
Annu. Rev. Fluid Mech.
0066-4189,
40
, pp.
367
393
.
21.
Lei
,
M.
,
Archie
,
J. P.
, and
Kleinsteuer
,
C.
, 1997, “
Computational Design of a Bypass Graft That Minimizes Wall Shear Stress Gradients in the Region of the Distal Anastomosis
,”
J. Vasc. Surg.
0741-5214,
25
(
4
), pp.
637
646
.
22.
Lei
,
M.
,
Giddens
,
D. P.
,
Jones
,
S. A.
,
Loth
,
F.
, and
Bassiouny
,
H.
, 2001, “
Pulsatile Flow in and End-to-Side Vascular Graft Model: Comparison of Computations With Experimental Data
,”
ASME J. Biomech. Eng.
0148-0731,
123
, pp.
80
87
.
23.
Walsh
,
M. T.
,
Kavanagh
,
E. G.
,
O’Brien
,
T.
,
Grace
,
P. A.
, and
McGloughlin
,
T.
, 2003, “
On the Existence of an Optimum End-to-Side Junctional Geometry in Peripheral Bypass Surgery—A Computer Generated Study
,”
Eur. J. Vasc. Endovasc Surg.
1078-5884,
26
, pp.
649
656
.
24.
O’Brien
,
T. P.
,
Grace
,
P.
,
Walsh
,
M.
,
Burke
,
P.
, and
McGloughlin
,
T.
, 2005, “
Computational Investigations of a New Prosthetic Femoral-Popliteal Bypass Graft Design
,”
J. Vasc. Surg.
0741-5214,
42
, pp.
1169
1175
.
25.
Moore
,
J. A.
,
Steinman
,
D. A.
,
Prakash
,
S.
,
Johnston
,
K. W.
, and
Ethier
,
C. R.
, 1999, “
A Numerical Study of Blood Flow Patterns in Anatomically Realistic and Simplified End-to-Side Anastomoses
,”
ASME J. Biomech. Eng.
0148-0731,
121
, pp.
265
272
.
26.
Giordana
,
S.
,
Sherwin
,
S. J.
,
Peiró
,
J.
,
Doorly
,
D. J.
,
Crane
,
J. S.
,
Lee
,
K. E.
,
Cheshire
,
N. J. W.
, and
Caro
,
C. G.
, 2005, “
Local and Global Geometric Influence on Steady Flow in Distal Anastomoses of Peripheral Bypass Grafts
,”
ASME J. Biomech. Eng.
0148-0731,
127
, pp.
1087
1098
.
27.
Jackson
,
M.
,
Wood
,
N. B.
,
Zhao
,
S.
,
Augst
,
A.
,
Wolfe
,
J. H.
,
Gedroyc
,
W. M. W.
,
Hughes
,
A. D.
,
Thom
,
S. A. M.
, and
Xu
,
X. Y.
, 2009, “
Low Wall Shear Stress Predicts Subsequent Development of Wall Hypertrophy in Lower Limb Bypass Grafts
,”
Artery Res.
,
3
, pp.
32
38
.
28.
Leotta
,
D. F.
,
Primozich
,
J. F.
,
Beach
,
K. W.
,
Bergelin
,
R. O.
,
Eugene
,
D.
, and
Strandess
,
J.
, 2001, “
Serial Measurement of Cross-Sectional Area in Peripheral Vein Grafts Using Three-Dimensional Ultrasound
,”
Ultrasound Med. Biol.
0301-5629,
27
(
1
), pp.
61
68
.
29.
Ansys, Inc.
, 2009, ANSYS® FLUENT®, release 12.1 ed.
30.
Lee
,
S. -W.
, and
Steinman
,
D. A.
, 2007, “
On the Relative Importance of Rheology for Image-Based CFD Models of the Carotid Bifurcation
,”
ASME J. Biomech. Eng.
0148-0731,
129
(
2
), pp.
273
279
.
31.
Womersley
,
J. R.
, 1955, “
Method for the Calculation of Velocity, Rate of Flow and Viscous Drag in Arteries When the Pressure Gradient Is Known
,”
J. Physiol.
,
127
, pp.
553
563
.
32.
Cantón
,
G.
,
Levy
,
D. I.
, and
Lasheras
,
J. C.
, 2005, “
Hemodynamic Changes Due to Stent Placement in Bifurcating Intracranial Aneurysms
,”
J. Neurosurg.
0022-3085,
103
(
1
), pp.
146
155
.
33.
Lee
,
S. -W.
,
Antiga
,
L.
, and
Steinman
,
D. A.
, 2009, “
Correlations Among Indicators of Disturbed Flow at the Normal Carotid Bifurcation
,”
ASME J. Biomech. Eng.
0148-0731,
131
(
6
), pp.
061013
.
34.
He
,
X.
, and
Ku
,
D. N.
, 1996, “
Pulsatile Flow in the Human Left Coronary Artery Bifurcation: Average Conditions
,”
ASMEJ. Biomech. Eng.
,
118
, pp.
74
82
.
35.
Fung
,
Y. C.
, 1993,
Biomechanics: Mechanical Properties of Living Tissues
,
Springer
,
New York
.
36.
Stroud
,
J. S.
,
Berger
,
S. A.
, and
Saloner
,
D.
, 2000, “
Influence of Stenosis Morphology on Flow Through Severely Stenotic Vessels: Implications for Plaque Rupture
,”
J. Biomech.
0021-9290,
33
, pp.
443
455
.
37.
Roach
,
M. R.
, 1963, “
An Experimental Study of the Production and Time Course of Poststenotic Dilatation in the Femoral and Carotid Arteries of Adult Dogs
,”
Circ. Res.
0009-7330,
13
, pp.
537
551
.
38.
Ojha
,
M.
, and
Langille
,
B. L.
, 1993, “
Evidence that Turbulence Is Not the Cause of Poststenotic Dilatation in Rabbit Carotid Arteries
,”
Arterioscler., Thromb., Vasc. Biol.
1079-5642,
13
, pp.
977
984
.
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