Risk evaluation of abdominal aortic aneurysms based on both sex and morphology

Abstract

Aim: To predict the peak wall stress in abdominal aortic aneurysms (AAAs) considering both morphological factors (maximum diameter, asymmetry index, and wall thickness) and sex differences, in order to assess the risk of AAA rupture more accurately.

Methods: Basic models of AAA focusing on different sexes with a range of morphological parameters were constructed. Using the Design-expert software for three-factor response surface methodology, 20 experimental models were built as well with the SolidWorks software. Fluid-structure interaction analysis was used to obtain stress distribution along the AAA wall. Polynomial regression equations were fitted to peak stresses in all experimental models.

Results: Based on fluid-structure interaction simulation data in the nonlinear polynomial regression model, separate equations for peak wall stress in AAA with regard to males and females were obtained. Morphological factors and sex differences have significant influence on peak wall stress. In some models, even when the maximum AAA diameter was relatively small, the peak wall stress became high. For the same maximal transverse measurement, when the AAA wall was thin and the asymmetry index large, or the former was thick and the latter small, the peak wall stress observed in males was higher than that in females.

Conclusion: To evaluate the risk of rupture of AAA more precisely and specifically, the present study proposes a new prediction method (based on equations) that includes more indicators such as sex and morphology, based on numerical biomechanical simulations, which were confirmed as such. This study provides a sex-specific clinical reference to assess the aforementioned risk of AAA rupture.

Keywords

Abdominal aortic aneurysm / sex difference / morphology / peak stress / rupture risk assessment

References

[1] McPhee JT,Eslami MH.The impact of sex on presentation, therapy and mortality of abdominal aortic aneurysm in the United States 2001-2004..J Vasc Surg2007;45:891-9

[2] Kontopodis N,Papaharilaou Y,Tsetis D.Advancements in identifying biomechanical determinants for abdominal aortic aneurysm rupture..Vascular2015;23:65-77

[3] Badger SA,Blair PH,Kee F.Endovascular repair or open repair for ruptured abdominal aortic aneurysm: a cochrane systematic review..BMJ Open2016;6:e008391 PMCID:PMC4762122

[4] Sakalihasan N,Defawe OD.Abdominal aortic aneurysm..Lancet2005;365:1577-89

[5] Powell JT,Sweeting MJ,Fowkes FGR.Rupture rates of small abdominal aortic aneurysms: a systematic review of the literature..Eur J Vasc Endovasc Surg2011;41:2-10

[6] Zhang N.Research progress of evaluation on abdominal aortic aneurysm rupture risk with morphological and biomechanical characteristics..Chin J Interventional Imaging Ther2011;8:443-6(in Chinese)

[7] Raghavan ML,Castro de Tolosa EM,Walker P.Regional distribution of wall thickness and failure properties of human abdominal aortic aneurysm..J Biomech2006;39:3010-6

[8] Vorp DA,Webster MW.Mechanical wall stress in abdominal aortic aneurysm: Influence of diameter and asymmetry..J Vasc Surg1998;27:632-9

[9] Gasser TC,Labruto F,Roy J.Biomechanical rupture risk assessment of abdominal aortic aneurysms: model complexity versus predictability of finite element simulations..Eur J Vasc Endovasc Surg2010;40:176-85

[10] Meng H,Xiang J.High WSS or low WSS? Complex interactions of hemodynamics with intracranial aneurysm initiation, growth, and rupture: toward a unifying hypothesis..AJNR Am J Neuroradiol2014;35:1254-62

[11] Davies PF,Barbee KA.A mechanism for heterogeneous endothelial responses to flow in vivo and in vitro..J Biomech1995;28:1553-60

[12] Gizzi A,Bini D,Filippi S.Three-band decomposition analysis of wall shear stress in pulsatile flows..Phys Rev E Stat Nonlin Soft Matter Phys2011;83:031902

[13] Cyron CJ,Humphrey JD.Mechanobiological stability: a new paradigm to understand the enlargement of aneurysms?.J R Soc Interface2014;11:20140680 PMCID:PMC4191096

[14] Tervahauta M.Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms..Acc Current Journal Review2002;11:1437-44

[15] Lowry D,Mytton J.Sex-related outcome inequalities in endovascular aneurysm repair..Eur J Vasc Endovasc Surg2016;52:518-25

[16] Mehta M,Robinson H,Paty PS.Women derive less benefit from elective endovascular aneurysm repair than men..J Vasc Surg2012;55:906-13

[17] De Rango P,Cieri E,Cao P.Association between sex and perioperative mortality following endovascular repair for ruptured abdominal aortic aneurysm..J Vasc Surg2013;57:1684-92

[18] Deery SE,Zettervall SL,Bodewes TCF.Sex differences in mortality and morbidity following repair of intact abdominal aortic aneurysm..J Vasc Surg2017;65:1006-13 PMCID:PMC5166615

[19] Powell JT,Brown LC,Greenhalgh RM.Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms..N Engl J Med2002;19:1445-52

[20] Forbes TL,DeRose G.Sex differences in relative dilatation of abdominal aortic aneurysms..Ann Vasc Surg2006;20:564-8

[21] Ash J,Hussain SM.Abdominal aortic aneurysms in women: the debate continues..Endovascular Today2018;17:51-6

[22] Lo RC.Abdominal aortic aneurysms in women..J Vasc Surg2016;63:839-44 PMCID:PMC4769685

[23] Solberg S,Wilsgaard T.Increased growth rate of abdominal aortic aneurysms in women..The Tromso stud. Eur J Vasc Endovasc Surg2005;29:145-9

[24] Dillavou ED,Makaroun MS.A decade of change in abdominal aortic aneurysm repair in the United States: have we improved outcomes equally between men and women?.J Vasc Surg2006;43:230-8

[25] Chaikof EL,Dalman RL,llliq KA.The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines..J Vasc Surg2009;50:S2-49

[26] Ulug P,von Allmen RS,Powell JT.Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis..Lancet2017;389:2482-91 PMCID:PMC5483509

[27] Darling RC,Brewster DC.Autopsy study of unoperated abdominal aortic aneurysms. The case for early resection..Circulation1977;56:II161-4

[28] Doyle BJ,Burke PE,Walsh MT.Vessel asymmetry as an additional diagnostic tool in the assessment of abdominal aortic aneurysms..J Vasc Surg2009;49:443-54 PMCID:PMC2666821

[29] Di Martino ES,Vande Geest JP,Makaroun MS.Biomechanical properties of ruptured versus electively repaired abdominal aortic aneurysm wall tissue..J Vasc Surg2006;43:570-6

[30] Wanhainen A,Ahlström H,Johansson L.Thoracic and abdominal aortic dimension in 70-year-old men and women-a population-based whole-body magnetic resonance imaging (MRI) study..J Vasc Surg2008;47:504-12

[31] Scotti CM,Muluk SC.Fluid-structure interaction in abdominal aortic aneurysms: effects of asymmetry and wall thickness..Biomed Eng Online2005;4:64 PMCID:PMC1298313

[32] Xu XH.Experimental design and design-expert, SPSS Application.2010;BeijingScience Press

[33] Olufsen MS,Kim WY,Nadim A.Numerical simulation and experimental validation of blood flow in arteries with structured-tree outflow conditions..Ann Biomed Eng2000;28:1281-99

[34] Norman PE.Abdominal aortic aneurysm: the prognosis in women is worse than in men..Circulation2007;115:2865-9

[35] Gatzka CD,Cameron JD,Liang YL.Sex differences in the timing of arterial wave reflection beyond differences in body height..J Hypertens2001;19:2197-203

[36] EI Baroudi A,Rakotomanana L.Fluid-structure interaction within three-dimensional models of an idealized arterial wall..Int J Eng Sci2014;84:113-26

[37] Zhao S,Gu L.Biomechanical prediction of abdominal aortic aneurysm rupture risk: sensitivity analysis..J Biomed Sci2012;5:664-71

[38] Villard C,Hanemaaijer R,Hultgren R.The composition of collagen in the aneurysm wall of men and women..J Vasc Surg2017;66:579-85

[39] Vande Geest JP,Di Martino ES,Bohra A.Gender-related differences in the tensile strength of abdominal aortic aneurysm..Ann N Y Acad Sci2006;1085:400-2

[40] Lindquist Liljeqvist M,Siika A,Roy J.Sex, smoking, body size, and aneurysm geometry influence the biomechanical rupture risk of abdominal aortic aneurysms as estimated by finite element analysis..J Vasc Surg2017;65:1014-21.e4

[41] Nestola MGC,Cherubini C.Three-band decomposition analysis in multiscale FSI models of abdominal aortic aneurysms..Int J Mod Phys C2016;27:1650017

[42] Bianchi D,Gizzi A,Filippi S.A FSI computational framework for vascular physiopathology: a novel flow-tissue multiscale strategy..Med Eng Phys2017;47:25-37

[43] Marino M.Narayan R.Constitutive modeling of soft tissues..Encyclopedia of biomedical engineering.2019;ElsevierOxford, UK81-110