Influence of catheter insertion on the hemodynamic environment in coronary arteries

https://doi.org/10.1016/j.medengphy.2016.06.013Get rights and content

Highlights

Abstract

Intravascular stenting is one of the most commonly used treatments to restore the vascular lumen and flow conditions, while perioperative complications such as thrombosis and restenosis are still nagging for patients. As the catheter with crimped stent and folded balloon is directly advanced through coronary artery during surgery, it is destined to cause interference as well as obstructive effect on blood flow. We wonder how the hemodynamic environment would be disturbed and weather these disturbances cause susceptible factors for those complications. Therefore, a realistic three-dimensional model of left coronary artery was reconstructed and blood flow patterns were numerically simulated at seven different stages in the catheter insertion process. The results revealed that the wall shear stress (WSS) and velocity in left anterior descending (LAD) were both significantly increased after catheter inserted into LAD. Besides, the WSS on the catheter, especially at the ending of the catheter, was also at high level. Compared with the condition before catheter inserted, the endothelial cells of LAD was exposed to high-WSS condition and the risk of platelet aggregation in blood flow was increased. These influences may make coronary arteries more vulnerable for perioperative complications.

Introduction

Intravascular stents are small tube-like structures expanded into stenotic arteries to restore blood flow perfusion for the downstream tissues that have become clogged by the build-up over time of fat, cholesterol or others substances [1]. After the first percutaneous coronary intervention (PCI) was performed, more than 1.8 million patients received one or more intracoronary stents annually [2]. The deployment of an intravascular stent has become a widely used and minimally invasive treatment for coronary heart disease [3].

With the widespread use of intravascular stents, perioperative complications have emerged, such as vessel spasm, thrombosis and restenosis [2], [4], [5], [6], [7]. Although rare, these complications are life-threatening complications during and shortly after PCI [8]. Sinha et al. reported that the repeated use of IVUS prior to PCI would result in cardiac arrhythmias and vessel spasm [9]. The antithrombotic and anticoagulant regimens, such as bivalirudin, heparin, glycoprotein IIb/IIIa inhibitors and so on, are essential to avoid thrombogenesis during PCI [10], [11], [12], especially for patients with acute coronary syndromes [13]. Even so, Buller et al. observed that unexplained cases of thrombosis primarily that involved PCI equipment despite administration of acetylsalicylic acid, clopidogrel, subcutaneous enoxaparin and abciximab [14]. On the other hand, De Feyter et al. have also reported that acute coronary artery occlusion during surgery often occasionally happened, and its frequency was higher in patients with unstable angina, multi-vessel disease, and complex lesions [15]. Regar et al. reported that restenosis was related to procedure-specific factor, which was affected by implantation technique [16].

The causes for these perioperative complications remain unknown, and some literatures reported the intraoperative factors such as the degree of damaged endothelial cells and depth of the injury, the plaque composition and shape, the type of intravascular stent expansion and local fluid dynamics [17], [18], [19], [20], [21]. As an essential and intricate part of intervention operation, the catheter insertion process was hardly considered as another potential factor for perioperative complications.

The catheter insertion process was destined to induce interference or hemodynamics change during surgery. Some published studies reported that the catheter or guidewire in coronary artery could exert obstruction effect on measuring pressure drops for the diagnosis of moderate stenosis, and resulting additional “artifactual” stenosis on the blood flow during operation [22], [23], [24], [25], [26]. However, these studies were just conducted with simple 2-D models or 3-D ideal models. The aforesaid interference or hemodynamics change could inevitably appear in realistic coronary arteries with irregular curvature and angulation, and might induce more complicated and serious effects [27]. These effects could directly act on hemodynamic factors such as WSS [28], which has been proved to induce morphological and functional changes in the endothelium and was critically important in regulating the atheroprotective and vessel wall dysfunction [29], [30], [31]. In addition, the previous paper reported the shear-induced platelet activation potency and the potential risk of catheter thrombose during clinical performance of these catheters [32]. Therefore, we hypothesized that the insertion process of catheter could disturb the hemodynamic environment in realistic coronary arteries and then cause susceptible factors, which might negatively make coronary arteries more vulnerable to those perioperative complications.

To test this hypothesis, a realistic coronary artery model was reconstructed based on CT scan images. Seven successive stages in the catheter insertion process were defined and the hemodynamic environment at these stages was numerically simulated. The main objective of the present study was to investigate the influence of catheter insertion process on hemodynamic environment in coronary arteries.

Section snippets

Artery model

The realistic left coronary arterial model was reconstructed based on the computed tomography (CT) scan images with Mimics software (v9.0, Materialise, Ann Arbor, MI, USA). The CT-relevant parameters were described below: 0.9 mm slice thickness, 0.45 mm slice increment, 0.324 mm pixel size, a 512×512 image resolution and total 293 slices. Subsequently simple smoothing and surfacing processes were applied to the model with Geomagic Studio 2012(3D Systems, Morrisville, NC, USA). The left coronary

Flow pattern

The velocity streamlines at four typical stages (Stage Origin and Stage 3, 5, 7) were showed in Fig. 2, which indicated no obvious disturbance of flow pattern in LCA in the catheter insertion process. However, compared with Stage Origin, this insertion process noticeably increased the flow velocity magnitude in LAD after catheter inserted into LAD (Stage 5). The flow velocity in LCxA and LIA was not observably altered.

Wall shear stress (WSS) distribution

The WSS contours in Fig. 3 depicted that the WSS on the wall of LAD increased

Discussion

Although intravascular stenting can reduce the postoperative morbidity and mortality, perioperative complications are still nagging for patients over time [4], [5], [6]. The causes remain unknown, and numerous studies have been conducted to investigate the potential influences of many postoperative and intraoperative factors [3], [4], [17], [21], [39], [40], [41], [42], [43], [44]. Only a few studies had reported that the catheter or guide-wire in coronary artery could exert obstruction effect

Conclusion

This study investigated the influences of the catheter insertion on hemodynamic environment in LCA during surgery. The results revealed that the insertion process could expose the endothelial cells of LAD to high-WSS condition, and the inserted catheter could increase the risk of platelet aggregation in blood flow. We concluded that these influences could make coronary arteries more vulnerable to perioperative complications. The present study concentrates on the rare but life-threatening

Conflicts of interest

There is no conflict of interest involved in the manuscript.

Funding

This work was supported by the National Natural Science Foundation of China (grant no.: 61190123, 11332003, 11472031, 31200703, 11421202), the 111 Project (B13003) and National Key Technology R&D Program of the Ministry of Science and Technology of China (2012BAI14B04).

Ethical approval

Not required.

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