Biomechanics and Modeling in Mechanobiology manuscript No.
(will be inserted by the editor)
Numerical study of the fluid-dynamics in coronary artery bypass grafts
A patient-specific approach
Francesco Ballarin Elena Faggiano Riccardo Ferrero
Abstract Coronary Artery Bypass Grafts (CABG) are asso-
ciated to many diseases such as atherosclerosis, atherogene-
sis and Intimal Hyperplasia (IH), which in time may reduce
the graft patency and cause a new occlusion and the need of
a new surgery. In this work we studied the effects of CABG
on blood flow in a patient specific 3D framework, studying
the physical parameters that are connected to the develop-
ment of coronary artery diseases.
Keywords CABG CFD LIMA SVG patient specific
1 Introduction
Coronary artery bypass graft surgery (CABG) is a proce-
dure used to treat coronary artery diseases in some circum-
stances. The most common Coronary Artery Disease (CAD)
is the narrowing of the coronary arteries, caused by a build-
up of fatty material within the walls of the arteries, so CABG
is one of the most frequent heart related surgery. One of
the biggest issue with CABG surgery is the development
of atherosclerosis in the implanted graft and consequent re-
occlusion of the vessels. The study of [1] show how long
time patency is a big issue in case of Saphenous Vein Grafts
F. Ballarin
MOX, Dipartimento di Matematica, Politecnico di Milano, Piazza
Leonardo da Vinci 32, 20133 Milano, Italy
E-mail: francesco.ballarin@polimi.it
E. Faggiano
MOX, Dipartimento di Matematica, Politecnico di Milano, Piazza
Leonardo da Vinci 32, 20133 Milano, Italy
E-mail: elena.faggiano@mail.polimi.it
R. Ferrero
Politecnico di Torino, Corso Duca degli Abruzzi 24, 10100, Torino,
Italy
E-mail: s180122@studenti.polito.it
ci saranno anche i clinici tra gli autori, completiamo dopo tutti i nomi
e affiliazioni, ora non e un problema
(SVG). After 10 years from the surgery 40% 50% of grafts
are occluded and only 25% show no angiographic evidence
of atherosclerosis. Internal Mammary Artery grafts (IMAs)
usually are patent for more years postoperatively (10-year
patency > 90%). Previous study showed a relation between
anastomotic Intimal Hyperplasia (IH) and haemodynamic
factors LoGerFo and also the mismatch between graft and
host artery Loth. More specifically Ojha analyzed the rela-
tion between low and oscillatory Wall Shear Stress (WSS)
and the rise of IH in end to side anastomoses. It was shown
that region of oscillatory WSS are zones of Low Density
Lipopotrein accumulation, which are the one responsible of
atherosclerosis soulis2011oscillating. Hughes have shown
that intimal hyperplasia occurs in regions of flow separation
at the toe and the heel, and that flow-stagnation is observed
on the floor of the anastomosis. It has been noticed the im-
portance of the effect of the geometry on the development
of the flow, in particular the local three dimensional curva-
ture Meyers-Moore, this study implyies that studies attempt-
ing to link hemodynamics with atherogenesis should repli-
cate the patient-specific geometry. We spent a lot of effort in
our work to obtain an accurate reconstruction of the patient
coronaries, and developed tools that allowed us to extrapo-
late the geometry in case of imperfection in the data.
2 Materials and methods
2.1 Patients and datasets
Our initial materials were the CTs provided by the hospital.
We conducted our study on four patients of different ages
that underwent CABG surgery. For each patient we run a to-
tal of four simulations, three with different degrees of steno-
sis ( 60%, 80%, 90%) and one where the stenosis were
removed.
2 Francesco Ballarin et al.

2.2 Imaging Table 1 Patients image data

Patient B Dimension 512 512 307

To ease the process of building a 3D model of the artery
and graft lumen from the high resolution CT 2.2, we applied
to the images an anisotropic filter implemented in 3D Slicer
(http://www.slicer.org/) initially developed by [2]. To further
enhance the vessel visibility we applied using the Vascular
Modeling Toolkit (vmtk, http://www.vmtk.org) the Frangi
filter developed by[3].Anisotropic diffusion is normally im-
plemented by means of an approximation of the generalized
diffusion equation: each new image in the family is com-
puted by applying this equation to the previous image. Con-
sequently, anisotropic diffusion is an iterative process where
a relatively simple set of computation are used to compute
each successive image in the family and this process is con-
tinued until a sufficient degree of smoothing is obtained. The
image is defined as a function I = I(x)
I : R3 R (1)
where x R3 are the spatial coordinate in the volume . Let
It = I(,t) be a family of images solutions of the diffusion
equation:
I some imperfections and artefacts from the CT, which may
= c(x,t) I + c(x,t) I (2)
t
where c(x,t) is the conductance term which allows to pre-
serve the edges. This term is a function of the gradient mag-
nitude of the image at each point,reducing the strength of
diffusion at edges,
1
c(x,t) =  2 . (3)
||I(x)||
1+ k
In our application the default parameters of 3D Slicer proved
to give good results. We tested some small parameters ad-
justment that, however, did not give dramatic improvement,
so we decided to stick with the default ones (k = 1, 5 itera-
tions).
To further enhance the vessel visibility we applied using the
Vascular Modeling Toolkit (vmtk, http://www.vmtk.org) the
Frangi filter developed by Frangi et al. (frangi). This filter is
able to recognize vessel-like structure at a given scale build-
ing this vesselness function: V0 (s) =
Resolution 0.36 0.36 0.70
Patient C Dimension 512 512 441
Resolution 0.39 0.39 0.33
Patient D Dimension 442 439 647
Resolution 0.37 0.37 0.33
value). The equation (4) can be interpreted as a probability-
like estimates of vesselness according to different criteria.
, and c are threshold parameters that the user can set in
vmtk. In our case and were fixed to 0.5, while c was
fixed to 7.0. The vesselness in (4) is analysed at different
scales between smin and smax , which is the range where we
expect to find the structures of interest.
2.3 Segmentation
We reconstructed the 3D surface of the CABG network of
each patients using the colliding front method developed
by[4] implemented in vmtk. The obtained surface despite
being very well tailored on the patients coronaries contained
cause abnormal reading of the parameters of interest. We
further processed the surface using the methods developed
for tubular structures antigatesi that describes the surface in
terms of its medial axes and embedde voronoi diagram.
2.4 Geometry improvement
Because the segmentation process included in the surface
some imperfection from the CT images, such as fictitious
aneurism or stenosis, we neeeded to find a way to remove
those without compromising the patient speific information
of the vessel. To do this we implemented five scripts, adapt-
ing to our needs the scripts written by M. Piccinelli based
on the study developed in [5], in order to obtain a smooth
patient specific 3D model of the coronaries.
Select points on the centrelines located upstream and
downstream in respect to the artefacts we wanted to elim-
inate.
Cut in correspondence of these points and re-interpolate

0 if 2 > 0 or 3 > 0, the centrelines with a spline .

2 2 (4) Take the Voronoi diagram, extract the centre of the Voronoi
S2
       
R R
1 exp a2 exp b2 1 exp 2 , sphere completely inscribed in the surface and the re-
2 2 2c
spective radius, smooth the diagram, and cut it in case of
p
where Ra = |1 |/ |2 3 | is a parameter that recognize blob- undesired stenosis/blobs .
like structure (small when 1 is small), Rb = |2 |/|3 | is Re-interpolate the Voronoi diagram if cut and generate a
a parameter that mesh from the diagram and the centrelines.
q recognize plane-like and line-like struc-
ture, and S = 12 + 22 + 32 is a parameter that distinguish We were able to remove imperfection eventually left over
background (low value) from the structure of interest (high with another tool, that allows the user to manually select a
Numerical study of the fluid-dynamics in coronary artery bypass grafts 3

zone, cut it away and re-interpolate the surface taking in ac- 2.400
LCA

count the curvature of the vessel in the neighbourhood of 2.000

the cut. With those scripts we were able to select the de-

LCA Blood Flow

1.500
formed portion of the vessel and to re-interpolate the sur-

mm3/s
face preserving the curvature and torsion of the vessel. We 1.000

subsequently generated for each patient a tetrahedral, radius 500

adaptive mesh.
0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
time s

2.5 Ghost vessel Fig. 1 Blood flow at LCA inlet.

In some case because of artifacts and rumor in the CT im-

RCA
ages the vessels were interrupted and we were not able to 1600

reconstruct the missing part with the normal procedure. To 1400

RCA Blood Flow

overcome this problem we developed a manual procedure 1200

mm3/s
that using modified version of the script allowed us to re- 1000

build the ghost vessels coherently with the coronary vessel 800

structure and the aim of a patient specific simulation. 600

400
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
time s

2.6 Stenosis Insertion Fig. 2 Blood flow at RCA inlet.

We proceeded to stenosis insertion. On a case test we evalu-

ated the effects of the stenosis shape on the flow and on the
which is not inf - sup stable so we introduced the interior -
parameter of interest, confronting a axial-symmetric steno-
penalty stabilization (see bibliograf`)
sis and a non axial-symmetric one. On the base of this re-
sults we decided to insert in each patient axial-symmetric
stenosis. Thanks to the evidence in the CT we individuated
the stenosis and their position, subsequently... qui fra spieghi
come hai deformato e inserito le stenosi?
2.8 Boundary conditions

2.7 Model
Two unsteady numerical simulations were performed for each
patient described above one with the stenosis and one where
the stenosis where removed, by using the finite element li-
brary LifeV (http://www.lifev.org). Blood was considered as
Newtonian, homogeneous, and incompressible. Blood vis-
cosity was set equal to 0.035 Poise and the density equal to
1.0 g/cm3 (O.K. Baskurt, M. Hardeman, M.W. Rampling,
H.J.). Being a preliminary study we decided to neglect the
Fluid Structure Interaction (FSI), so we supposed to be un-
der the hypothesis of rigid and impervious wall and to ne-
glect thermal effects. We are able to describe the blood flow
with the incompressible Navier-Stokes equations.
puted starting from a medium flow we researched in the ex-
u (2D(u)) + (u )u + p = f, x , t > 0
t
For each outlet we prescribed the usual zero stress condi-
tion wellnhofer 504367 For the Coronary Artery (CA) in-
let it was proved that the shape of the inlet profile on the
developed flow patterns, and especially on the WSS distri-
butions is not dramatically significant [6]. The difficulty to
determine in practice the velocity profile developed in the
coronary artery of interest for a given patient, due in part
to the complex nature of flow especially in proximity of the
ostium and the great intra-patient variability of coronary ge-
ometry, and to the absence of a non-invasive technique for
its measurement in clinic practice, led us to choose a time
dependent flat velocity profile normal to the inlet surface.
For each patients the velocity profile of the Left Coronary
Artery (LCA) and Right Coronary Artery (RCA) was com-
isting literature [7] dividing it by the inlet area.

u = 0, x , t > 0 dai risultati sul paziente D nn ho riscontrato grosse vari-

(5)
The time step was chosen equal to 0.01 s each simulation
was run for two cardiac cycle for a total of 1.6 s. We dis-
cretized the problem in space with a P1 - P1 finite element
azioni nel flusso o nei valori di wss e osi per cui x le simu-
lazioni ho tenuto LIMA vecchia anche per non dover rifare
tutte quelle che avevamo ancora The flow at the inlet is simi-
lar to others we find in similar literature intima opportunely
reshaped and adapted to the patient diameter ostium.
4 REFERENCES
10000
8000
LIMA Blood Flow
6000
mm3/s
4000
2000
0
0 0.1 0.2 0.3 0.4 0.5
time s
Fig. 3 Blood flow at LIMA inlet.
2.9 Quantitative measures
We wanted to evaluate the effect of the bypass on blood cir-
culation, and to study critical regions of the vessel or of the
graft where re-occlusion may occur in the future. We briefly
resume the quantities we analyzed.
Velocity field. Those allow us to see how the bypass modi-
fies the blood flow and show how in case of small stenosis
unnecessary surgery can lead to non physiological situation
such as recirculation zones, or in the worst case to the atro-
phy of the graft (especially for IMAs) . This is one of the
reason why bypass surgery is made only in case of severe
stenosis, other than the surgery risks.
Wall Shear Stress (WSS). It is one of the main indices re-
lated to the re-occlusion of coronaries after surgery. Intimal
hyperplasia is the thickening of the tunica intima, it is the
universal response of a vessel to injury. Particularly patho-
logically low and oscillating WSS is supposed to enhance
atherogenesis and Intimal Hyperplasia (IH) whereas physi-
ological flow confers protective training of the arterial wall
. Moreover high WSS are also responsible of risk of throm-
bosis see and related. WSS is defined as
W SS = t (t n)n,
where t = Tn is the force applied to the wall with normal n
and T is the stress tensor.
Oscillatory Shear Index (OSI). It is defined as
Streamlines. Those are used to evaluate the regularity of the
flow, with them we are able to clearly individuate regions of
recirculation or stagnation.
3 Results
0.6 0.7 0.8
4 Conclusions
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 T
 stress distribution of left coronary arteries in patient-
 0 W SS(t)dt 

OSI = 0.5 1 R T
, 0 OSI 0.5
0 |W SS(t)|dt
where T is the period of a cardiac cycle. A value for the OSI
near 0 means that the flux is almost mono-directional and
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REFERENCES 5

Table 2 Non-Stenotic Mesh Parameters

Patient A B C
# of thetra. 944564 1126486 1948337
h 0.00337 0.00339 0.00390