(Circulation. 2001;103:1740.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Relationship Between Neointimal Thickness and Shear Stress After Wallstent Implantation in Human Coronary Arteries
From the Department of Cardiology (J.J.W., R.K., J.C.H.S., J.A.O., J.K., W.J.v.d.G., P.W.S., C.J.S.), Thoraxcenter, Erasmus Medical Centre Rotterdam and Erasmus University Rotterdam, and the Interuniversity Cardiology Institute of the Netherlands (J.J.W.), Utrecht, the Netherlands.
Correspondence to C.J. Slager, PhD, Thoraxcenter, EE2322, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, the Netherlands. E-mail slager{at}tch.fgg.eur.nl
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Abstract |
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Background—In-stent restenosis by excessive intimal hyperplasia reduces the long-term clinical efficacy of coronary stents. Because shear stress (SS) is related to plaque growth in atherosclerosis, we investigated whether variations in SS distribution are related to variations in neointima formation.
Methods and Results—In 14 patients, at 6-month follow-up after coronary Wallstent implantation, 3D stent and vessel reconstruction was performed with a combined angiographic and intravascular ultrasound technique (ANGUS). The bare stent reconstruction was used to calculate in-stent SS at implantation, applying computational fluid dynamics. The flow was selected to deliver an average SS of 1.5 N/m2. SS and neointimal thickness (Th) values were obtained with a resolution of 90° in the circumferential and 2.5 mm in the longitudinal direction. For each vessel, the relationship between Th and SS was obtained by linear regression analysis. Averaging the individual slopes and intercepts of the regression lines summarized the overall relationship. Average Th was 0.44±0.20 mm. Th was inversely related to SS: Th=(0.59±0.24)-(0.08±0.10)xSS (mm) (P<0.05).
Conclusions—These data show for the first time in vivo that the Th variations in Wallstents at 6-month follow-up are inversely related to the relative SS distribution. These findings support a hemodynamic mechanism underlying in-stent neointimal hyperplasia formation.
Key Words: stents • restenosis • coronary disease • stress
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Stents have been shown to reduce restenosis by preventing the artery from arterial shrinkage (negative remodeling). However, excessive neointima formation may still be observed, causing renarrowing of the treated arteries.1 2
Neointima formation is often observed at specific locations in the stented segment.3 A number of risk factors, such as thrombus formation4 and endothelial dysfunction,5 are related to restenosis, but their relationship with a specific intima hyperplasia distribution is unknown. Localizing factors that have been studied include plaque burden6 7 and wall stress.8 In the present study, we focus on the role of shear stress (SS). SS plays an important role in growth-related processes.9 10 For instance, low SS regions in vascular bypass grafts show increased neointimal growth.11
To study localization patterns of SS and neointimal thickness (Th), we applied a recently developed technique that combines a 3D reconstruction technique (ANGUS12 ) with computational fluid dynamics. Our aim was to investigate the relationship between local variations in SS and Th after stent placement to evaluate the hypothesis that low SS locations show more neointimal growth than locations with high SS.
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Methods |
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Patients
Fourteen patients were studied 6 months after implantation of a coronary Wallstent (Schneider AG). Only patients with <3 major side branches in the stented segment were included in the present study. Table 1
reports the demographic parameters and risk factors
of the patient population. Written informed consent was obtained
from every patient to participate in this study, which was approved by
the institutional medical ethics committee.
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3D Reconstruction
3D reconstruction of the coronary arteries was
performed by applying a combination of ANGiography and intravascular
UltraSound (ANGUS).12 A
detailed description of the 3D reconstruction method has been presented
elsewhere.12 Briefly, a
sheath-based intravascular ultrasound (IVUS) catheter (CVIS 2.9F) was
positioned distally from the stented vessel segment and was filmed with
a biplane angiographic system (Siemens, Bicor) just after the start of
pullback. To eliminate respiratory and cardiac motion artifacts, a
single biplane view at end diastole of the catheter position was
selected and digitized. From the biplane views, the transducer path was
reconstructed in 3D space.12
In addition, (IVUS) images were collected at end diastole with an
ECG-triggered, motorized pullback operating with a step size of 0.5 mm
(TomTec). Subsequently, the frames were digitized and analyzed with a
semiautomatic contour-detection
program.13 Output of the
program consisted of lumen contours, signifying the blood-vessel
interface, and stent contours, representing the stent-neointima
interface.
Figure 1A displays these respective borders.
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Subsequently, the lumen contours were filtered and positioned perpendicularly onto the reconstructed 3D catheter path, which served as a backbone for the reconstruction. The same procedure was performed for the stent contours only. The angular position of the ultrasound transducer, and thus of the ultrasound images, was determined from a comparison between simulated silhouette images derived from the 3D stent reconstruction with the actual coronary stent angiogram.12 Finally, two 3D reconstructions were obtained from (1) the coronary vessel lumen and (2) the stent contours only. The 3D reconstruction of the stent was used as the approximate lumen after stenting to calculate SS at the stent surface.
Computational Fluid Dynamics
For SS calculations, the nonlinear, incompressible 3D
Navier Stokes equations need to be solved. For this purpose, a
well-validated finite-element software package (Sepran, Sepra) was
used, which was implemented on a workstation (Hewlett Packard 715/80).
For application of such a finite-element method, it is necessary to
subdivide the 3D space into bricks ("mesh generation") and to
define appropriate boundary conditions.
Mesh Generation
To generate a mesh of the 3D reconstructed lumen, the
vessel was axially divided into 
100 cross sections (axial resolution
0.2 to 0.9 mm). Each cross section contained 32 bricklike elements,
each covering a cross-sectional surface ranging from 0.05 to 0.83
mm2, with the highest resolution near the
wall. Each element contained 27 nodes. The same procedure was applied
to the 3D reconstruction of the stent. The axial resolution of the mesh
in the stent was equal to the resolution of the mesh in the
lumen.
Boundary Conditions and Numerical
Solution
The Navier Stokes equations were implemented in each
node of the mesh. The nonlinear convective terms in these equations
were linearized by a Newton-Raphson method. To obtain the pressure
unknowns, a penalty-function approach was used. In combination with the
boundary conditions, the differential equations were solved with a
numerical accuracy of 0.1 mm/s by applying a direct-profile
method.14 We used the
following assumptions and boundary conditions.
We assumed that blood behaves as a Newtonian fluid with a
viscosity of 3x10-3 Pa·s and a density
of 1050 kg/m3. Because our aim was to
investigate the distribution of SS variations, this assumption would
not affect our results.15 At
the wall, no-slip conditions were applied, and at the outflow,
zero-stress conditions were applied. Because the diameter of the
stented vessel segment will generally be restored to normal dimensions,
it was assumed that a normal value for SS, ie, 1.5
N/m2, would be
obtained.16 17
Therefore, the selected entrance flow to induce this average SS in each
stent reconstruction was calculated from the Poisseuille formula and
the average stent diameter. As a first numerical calculation, this
entrance flow was applied to the proximal lumen of the artery, with a
parabolic profile, to obtain the velocity profiles in the lumen of the
artery. Second, from the obtained 3D velocity profiles in the lumen at
the entrance of the stent, the entrance velocity profile to be used for
the bare stent reconstruction was derived
(Figure 1B
). For this purpose, the profile was magnified in
area and shape to fit the stent entrance, while maintaining the
previously determined flow. Only the latter entrance condition
determined the SS at the surface of the stent used in the present
study.
Analysis of Th and SS
Only the stented vessel segments were analyzed. The
locations of side branches were selected with the help of the IVUS
data, and cross sections containing the side branch, as well as
adjacent segments with a length equal to the diameter of the side
branch, were removed from our data set. Furthermore, a part of the
entrance and exit of the stent, covering a length of 1 stent diameter,
was excluded from the data set. This minimized the influence of the
inflow velocity profile, as well as of the outflow conditions, on our
results. The following parameters, based on either the 3D vessel
geometry or 3D velocity calculations, were calculated with in-house
developed software implemented in Matlab (Mathworks Inc).
The location of the inner and outer curve of the 3D reconstructions was calculated with a plane fitted through all points of the geometric centers of the lumen. In each cross-sectional IVUS plane, the vector passing through the center of mass and parallel to the fitted plane indicated the inner and outer vessel wall, respectively.
For each cross section, the distance between lumen and stent contours determined Th at 16 locations over the vessel circumference. The Th was filtered in the axial and circumferential direction by a 5x5-point moving average filter. For each cross section, the minimal and maximal Th was determined, and their location was compared with the location of the outer and inner curve.
For the cross sections near the stent edges, the Th was calculated and filtered as described previously. Average Th at the edges was compared with thickness in the remaining part of the stent.
SS at the stent surface was calculated from the product of the local velocity gradient at the wall and viscosity. The SS values were also filtered by application of a 5x5-point moving average filter. For each cross section, the minimal and maximal SSs were determined, and their location was compared with the location of the inner and outer curve.
The ratio of the maximal to the minimal value of the Th and SS at each cross section was used as an asymmetry index. For each artery, the average of the local asymmetry indexes was calculated.
Statistics
A paired t
test was used to compare average Th at the stent edges with the average
thickness of the central part. The relationship between SS and Th, for
each vessel separately, was studied by linear regression analysis.
Averaging the obtained individual slopes and intercepts summarized the
relationship between Th and SS. Student’s
t test or univariate regression
analysis was used to test the influence of the demographic parameters
and risk factors on the slope of the relationship between Th and SS,
average Th, and the asymmetry index for Th. A
P value of <0.05 was
considered significant. All values were expressed as mean±SD. SPSS
version 8.0 was used for all statistical
calculations.
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Results |
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For all patients, 3D reconstruction of the coronary arteries and stents was performed successfully. Figure 2
shows a 3D reconstruction of a right coronary
artery 6 months after Wallstent implantation, showing vessel lumen and
vessel wall.
Table 2 shows angiographic data of the patients before and
after stent implantation and at follow-up. During the follow-up period,
the stent length decreased by 2.7% (paired
t test,
P<0.05).
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Neointimal Thickness
The Th for the entire group of patients was 0.44±0.13
mm.
Figure 3 shows an example of a 2D map of Th from which the
asymmetrical pattern can be clearly observed. The average of the
minimal and maximal Th for the entire group of vessels was 0.30±0.10
and 0.58±0.16 mm (P<0.05),
respectively. The average of all asymmetry indexes was 2.04±0.36,
being different from 1
(P<0.05). The average Th at
the stent entrance (0.43±0.20 mm) was not different from that at the
mid part (0.44±0.12 mm) or at the exit of the stent (0.45±0.13 mm)
(paired t test,
P=NS).
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Male patients tended to have greater Th (0.50±0.12 mm) than female patients (0.37±0.11 mm, P=0.055), whereas Th was inversely related to the age of the patient [Th=(0.84± 0.19)-(6.4x10-3±2.9x10-3)xage mm; P=0.049].
Shear Stress
The average SS for the entire group of vessels was
1.99± 0.24 N/m2.
Figure 4 shows a 2D map of the SS corresponding to the
example shown in
Figure 3. For the entire group of patients, the averages of
minimal and maximal SS values were, respectively, 1.39±0.27 and
2.57±0.55 N/m2
(P<0.05). The average of the
asymmetry indexes was equal to 2.12±0.96, being different from 1
(P<0.05).
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Th Related to SS
For 9 of 14 vessels, an inverse relation
(r=0.04 to 0.65) between Th and
SS was observed
(Figure 5). Intimal thickness at the low SS locations was
higher than at the high SS locations
(P<0.05). The average
relationship between Th and SS was Th=(0.59±0.24)-(0.08±0.10)x SS
mm (P<0.05; 95% CI slope
-0.14 and -0.02; intercept 0.45 and 0.72). Of all the tested
parameters and risk factors, only a history of hypercholesterolemia
affected this relationship. For patients without such history (n=9),
the relationship was Th=(0.69±0.19)-(0.12±0.10)x SS mm
(P<0.05; 95% CI slope -0.18
and -0.05; intercept 0.57 and 0.81) and for patients with a history
of hypercholesterolemia (n=5), it was Th=(0.40±0.23)-(0.007±0.06)x
SS mm (P=NS; 95% CI slope
-0.05 and 0.06; intercept 0.2 and 0.6).
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The geometric relationship between Th and SS can be
appreciated from a presentation of the location of the lesions and of
the location of low or high SS in relation to vessel geometry.
Figure 6A shows the distribution of the difference in angle
between the location of the inner curve and the location of the maximal
Th in the cross-sectional plane. In
Figure 6B, a similar graph is displayed for the minimal SS
location related to the location of the inner curve. A combined 3D view
of these data
(Figure 6E) revealed that the maximal Th was preferentially
located near the inner curve of the coronary artery, where the minimal
SS was also observed. Similarly, the minimal Th was more frequently
detected in the outer curve
(Figure 6C), which is primarily where the maximal SS was also
located
(Figure 6D). The latter correspondence in location was less
pronounced than the former, as can also be appreciated from
Figure 6F.
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Discussion |
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Although neointimal hyperplasia was moderate in the present study, a significant asymmetry in its cross-sectional distribution was observed. Neither the average neointimal hyperplasia nor its asymmetrical distribution could be explained by well-accepted risk factors. However, neointimal hyperplasia distribution was related to SS distribution, such that compared with average values, low SS regions were accompanied by maximal intimal thickness and high SS regions by minimal Th.
Neointimal Thickness
The observed average Th of 0.44 mm implies a diameter
loss of 0.88 mm, which is comparable to our observed 1.09 mm
angiographic change in minimal luminal diameter. Other studies of
Wallstent implantation in native human coronaries reported a late loss
of 0.78±0.61
mm.18 19
The similarity in Th at the edges and the mid part of the stent is in contrast to observations in the Palmaz Schatz stent, where more neointima formation was observed at the edges and in the middle near the articulation.20 These differences may be caused by the differences in stent design, such as the existence of an articulation in the Palmaz Schatz stent.20
Shear Stress
The average SS in the bare stents derived from the
fluid dynamic finite-element calculations was 1.99
N/m2. This is above the aimed level of 1.5
N/m2. Variations in the actual diameters,
together with the third-order power relation between SS and diameter,
explain the above finding. In the present study, the relationship
between Th and SS is investigated in a relative sense, ie, high SS
regions are compared with low SS regions. In previous
work,21 we showed that for a
wide variety of flow entrance conditions, the same distribution pattern
of low and high SS regions was found. Therefore, we do not expect that
the choice for the entrance flow conditions, based on the average SS
values to be expected,17
will affect the inverse relation of neointimal variation versus SS
distribution.
Relation Between SS and Th
Factors thought to be responsible for neointima
formation are mostly systemic in nature and are not likely to be
responsible for the observed asymmetrical pattern in neointima
formation. Indeed, in the present study, no relationship between the
demographic factors and the asymmetry index for neointima was observed,
and thus, local factors must be involved in this process. In the
present study, SS is proposed as such a local factor.
From a global observation of our geometrical data
(Figure 6), it became apparent that SS and neointimal
asymmetry were interrelated. However, in contrast to earlier
work,21 in the present study
we also wanted to investigate the relation between SS and intimal
thickness variations in the axial vessel direction. Indeed, this
extension appeared to be crucial to reach statistically significant
results. Therefore, the study of only the cross-sectional data will
underestimate the importance of SS in relation to Th, particularly in
this population of stented patients. This probably has to do with axial
SS variations within the stent, as has been presented
previously.22
The observed relation between relative SS distribution and Th distribution shows similarity with results of animal studies of neointima formation in bypass grafts.11 23 In these studies, SS was measured in a global way. Low SS was related to neointimal growth,11 and high SS inhibited neointima formation.11 23
Wall stress is another local factor that may influence Th. It is sensed by the arterial wall, and in normal arteries, the wall thickness adapts to the local radius to control wall stress. Whether variations in wall stress exerted by the stent can influence wall asymmetrical thickening is not clear. Vorwerk et al8 showed that differences in radial force of a Wallstent did not influence neointimal hyperplasia formation. We reasoned that for stability, average force exerted by a stent on the wall of the inner curve must equal average force exerted on the outer wall. The outer surface wall area slightly exceeds the inner wall area, and therefore we expect the wall stress difference between the outer and inner walls to differ by the ratio of these areas. In our range of curvatures and vessel diameters, we estimate this difference as <10%, which is far less than the observed difference in SS between inner and outer curves (by a factor of 2). In addition, because the observed relation between vessel wall thickness and wall stress24 is linear, we do not expect that a 10% wall stress variation will produce a 100% variation in neointimal hyperplasia.
Another often-described local risk factor for local promotion of neointimal hyperplasia is the persistent plaque burden covered by the stent.6 7 However, previous studies only report on the relationship between cross-sectional area of the plaque burden and cross-sectional area of the neointima formation.6 7 No data exist as to whether the asymmetries in neointimal formation may be explained by the eccentricity of the persistent plaque burden. This subject warrants further study because in eccentric lesions, a confounding factor, such as progression of atherosclerosis at the low SS21 side, may be present. In contrast with this, the balloon-induced damage and healing response may be located opposite of the plaque at the remaining free wall.
Of the investigated parameters and risk factors, only a history of hypercholesterolemia was found to abolish the slope of the relationship between Th and SS, whereas mean Th was not different. Although we did not intend to investigate this subject when we designed the present study, we thought the reporting of this post hoc finding to be relevant for future research in this area. From animal and patient studies, it is known that SS-dependent endothelial functions involved in neointima formation, such as nitric oxide and endothelin production,25 26 are influenced by hypercholesterolemia. However, because the majority of the patients received cholesterol-lowering drugs to normalize cholesterol levels after enrollment in this study, this does not explain the observed difference. Whether the history of hypercholesterolemia may be related to long-term persistent changes in endothelial cell phenotype is unknown, and further studies are warranted in this area.
Limitations of the Study
In this study, only patients with intermediate
neointima formation and no restenosis could be studied, because the
stepped IVUS pullback device could only be applied for those patients.
Therefore, our results could be biased and only concern mildly
neointimal hyperplasia.
In this study, no flow measurements were performed. Therefore, it was not possible to evaluate the effects of absolute differences in SS levels between patients.
For the 3D reconstruction of the stents and subsequent computational fluid dynamics, only vessel geometries at 6 months were available. Therefore, changes in geometry over the follow-up period might have influenced our results. However, the observed 3% change in stent length is relatively small. Furthermore, it is not likely that this minor change is responsible for the observed asymmetrical pattern in Th.
Conclusions
The variations in Th in Wallstents evaluated at 6-month
follow-up after implantation are inversely related to the relative SS
distribution. These findings support a hemodynamic mechanism
contributing to the process of in-stent neointimal hyperplasia
formation.
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Acknowledgments |
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Financial support of the Interuniversity Cardiology Institute of the Netherlands for Dr Wentzel is gratefully acknowledged.
Received October 18, 2000; revision received December 7, 2000; accepted December 15, 2000.
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J. J. Wentzel, R. Corti, Z. A. Fayad, P. Wisdom, F. Macaluso, M. O. Winkelman, V. Fuster, and J. J. Badimon Does shear stress modulate both plaque progression and regression in the thoracic aorta?: Human study using serial magnetic resonance imaging J. Am. Coll. Cardiol., March 15, 2005; 45(6): 846 - 854. [Abstract] [Full Text] [PDF]
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T. Shimizu, S. Ito, Y. Kikuchi, M. Misaka, T. Hirayama, S. Ishimaru, and A. Yamashina Arterial conduit shear stress following bypass grafting for intermediate coronary artery stenosis: a comparative study with saphenous vein grafts Eur. J. Cardiothorac. Surg., April 1, 2004; 25(4): 578 - 584. [Abstract] [Full Text] [PDF]
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P. H. Stone, A. U. Coskun, S. Kinlay, M. E. Clark, M. Sonka, A. Wahle, O. J. Ilegbusi, Y. Yeghiazarians, J. J. Popma, J. Orav, et al. Effect of Endothelial Shear Stress on the Progression of Coronary Artery Disease, Vascular Remodeling, and In-Stent Restenosis in Humans: In Vivo 6-Month Follow-Up Study Circulation, July 29, 2003; 108(4): 438 - 444. [Abstract] [Full Text] [PDF]
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S. G. Carlier, L. C.A. van Damme, C. P. Blommerde, J. J. Wentzel, G. van Langehove, S. Verheye, M. M. Kockx, M. W.M. Knaapen, C. Cheng, F. Gijsen, et al. Augmentation of Wall Shear Stress Inhibits Neointimal Hyperplasia After Stent Implantation: Inhibition Through Reduction of Inflammation? Circulation, June 3, 2003; 107(21): 2741 - 2746. [Abstract] [Full Text] [PDF]
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J. F. LaDisa Jr., D. A. Hettrick, L. E. Olson, I. Guler, E. R. Gross, T. T. Kress, J. R. Kersten, D. C. Warltier, and P. S. Pagel Stent implantation alters coronary artery hemodynamics and wall shear stress during maximal vasodilation J Appl Physiol, December 1, 2002; 93(6): 1939 - 1946. [Abstract] [Full Text] [PDF]
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A. Colombo, G. Stankovic, and J. W. Moses Selection of coronary stents J. Am. Coll. Cardiol., September 18, 2002; 40(6): 1021 - 1033. [Abstract] [Full Text] [PDF]
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N. H.J. Pijls, V. Klauss, U. Siebert, E. Powers, K. Takazawa, W. F. Fearon, J. Escaned, Y. Tsurumi, T. Akasaka, H. Samady, et al. Coronary Pressure Measurement After Stenting Predicts Adverse Events at Follow-Up: A Multicenter Registry Circulation, June 25, 2002; 105(25): 2950 - 2954. [Abstract] [Full Text] [PDF]
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