Flow in the Vascular System Post Stent Implantation: Examining the Near-Stent Flow Physics to Guide Next-Generation Stent Design
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The prevalence of cardiovascular disease (CVD) has increased dramatically due in part to the increased rates of obesity in North America. Atherosclerosis, the most prevalent type of CVD, is a progressive disease characterized by the build-up of plaque within the arteries. The plaque development leads to the narrowing of arteries, referred to as stenosis, and restricts crucial blood flow to the organs of the body. This condition is often treated by the implantation of a stent, a wire mesh scaffold device placed in the region of an atherosclerotic plaque after balloon angioplasty. The stent was developed to improve the clinical outcome of angioplasty procedures by mitigating the effects of elastic recoil by the vessel wall and maintaining vessel patency after angioplasty. Since the introduction of stents as a treatment option over a decade ago, in-stent restenosis (ISR) has been an iatrogenic outcome and remains an unsolved limitation of the interventional treatment device, resulting in stent failure and additional surgical procedures to restore blood flow. Many improvements have been made in stent design in order to reduce the likelihood of ISR, but none have eliminated the problem. Endothelial cells lining vessel walls transduce local hemodynamic loading in the stent vicinity, such as wall shear stress magnitude (WSS), into biochemical signals that lead to the progression of ISR. Hence, resolving the hemodynamics in the vicinity of the stent is crucial to reducing the rates of stent failure. The objective of the study is to address the problem of ISR by clearly elucidating the flow physics induced by stent implantation, accounting in particular for vessel curvature, by first considering idealized stent models, then progressing to an actual stent model. Stent designs are typically based upon data originating solely from studies of flow in straight vessels, which, once optimized for this configuration, may lead to suboptimal performance when placed in tortuous vessels. Previous stent studies have almost categorically neglected the effects of curvature on the flow physics, despite the fact that even extremely mild curvature changes the axial WSSM distribution within the vessel and induces the development of secondary flows, which alters the advection of chemicals released into the lumen. Using computational fluid dynamics (CFD) techniques, this study seeks to (i) determine the impact of stent strut amplitude and frequency on primary and secondary flow structures; (ii) determine the significance of the stent strut shape in the size of the stagnation zone; (iii) evaluate flow behavior in the transition region from smooth walled to stented vessel; and (iv) examine the collection of these effects in a full stent model geometry in a curved tube. This study takes a systematic approach, dissecting the impact of the stent first into simplified foundational components, then investigating each component and finally synthesizing the components into a full stent model with the long-term goal of optimizing stent design to reduce the rate of restenosis. As well, the study findings can aid in understanding the signal transduction mechanisms of the endothelial cells, which play a role in the development of ISR, and reduce the cardiovascular disease mortality rate by improving the clinical outcome of treatment procedures. Further, the study findings contribute to the fundamental understanding of flow in curved pipes with wall protrusions, the impact of the choice of the constitutive model of the fluid, and the hemodynamic environment in the vicinity of the stent.