Bio Stent

ANRV294-FL39-15 ARI 12 December 2006 6:5
Stented Artery Flow

Patterns and Their Effects
on the Artery Wall
Annu. Rev. Fluid Mech. 2007.39:357-382. Downloaded from arjournals.annualreviews.org
by Deutsche Forschungsgemeinschaft on 06/06/07. For personal use only.
Nandini Duraiswamy,2
Richard T. Schoephoerster,2 Michael R. Moreno,1
and James E. Moore, Jr.1
1
Texas A&M University, College Station, Texas 77843;
email: michael.moreno@tamu.edu, jmoorejr@tamu.edu
2
Florida International University, Miami, Florida 33199; email: ndura002@u.edu,
schoepho@u.edu
Annu. Rev. Fluid Mech. 2007. 39:35782 Key Words

The Annual Review of Fluid Mechanics is online uid mechanics, stents, hemodynamics, wall shear stress,
at uid.annualreviews.org
neointimal thickness
This articles doi:
10.1146/annurev.uid.39.050905.110300 Abstract
Copyright c 2007 by Annual Reviews. Stent design and geometry inuence the uid mechanical environ-
All rights reserved
ment in an artery and hence affect clinical outcomes of restenosis.
0066-4189/07/0115-0357$20.00 There is clearly a role for biomechanics in improving current stent
designs. This review summarizes some of the work that has been
done to address the uid mechanical aspects of stenting. A variety
of computational, experimental, and in vivo approaches have been
employed, and the results demonstrate a strong dependence on stent
design, as well as effects on hemodynamics in locations of the circu-
latory system quite removed from the stented segment. There are
also important solid mechanical aspects that affect clinical failures of
stents that are not summarized here.
357
INTRODUCTION
Arterial diseases remain the most common cause of death and disability in western
Stent: Metallic scaffold countries. More than 71 million Americans suffer from cardiovascular disease (mainly
used to keep arteries open atherosclerosis), with approximately 7 million having suffered a heart attack (Thom
after angioplasty et al. 2006). There are two principal manifestations of atherosclerosis: occlusive dis-
Balloon angioplasty: ease, which can limit blood ow to the tissues downstream, and aneurysms, which
Expansion of an are local enlargements in artery diameter usually accompanied by thinning of the
atherosclerotic plaque with
arterial wall. The distribution of atherosclerosis development is not uniform in the
ination of a catheter-tip
balloon cardiovascular system, but is conned to the coronary arteries and the arteries leading
to the brain and legs. Traditional treatment strategies were mainly limited to open
surgery until the development of catheter-based therapies such as angioplasty and
stents.
The pioneering work of Charles Dotter in the 1960s with catheter-based treat-
ment of occlusive arterial disease opened up new possibilities for clinicians and their
patients. Procedures could be performed with local anesthesia, and consequently re-
covery times were greatly shortened relative to open surgery. At rst, catheters were
used to force open blockages, or stenoses. This eventually evolved into balloon-tipped
catheters that could be guided uoroscopically to the desired treatment site and ex-
panded with pressurized saline solution. Failure rates were relatively high (over 50%),
due in large part to acute closure of the vessel. Arteries and atherosclerotic plaques
can be quite elastic, and in many cases may return to their original diameter when the
balloon is removed. There is also a problem with tissue rupture, which could result
in aps protruding into the ow stream.
Stents are small metallic tubes intended to prop open arteries. These devices were
actually under development in the 1960s as well. At that time, the shape memory char-
acteristics of alloys such as Nitinol were exploited to create what eventually became
known as self-expanding stents. These stents are designed to possess a relaxed diam-
eter slightly larger than the target vessel. They are then compressed into catheters
for deployment. Once delivered to the treatment site, they are expelled from the
catheter and expand into the artery wall. The expansion can occur either due to the
shape memory characteristics, or due to the fact that Nitinol has so-called superelastic
properties (Stoeckel et al. 2004). In this case, the ability to handle up to an 8% strain
is exploited to compress the stent into the catheter. Although this technology remains
in use today in some stents, there is still a desire to deploy the stent at the same time
as the balloon angioplasty procedure.
In the early 1980s, Dr. Julio Palmaz began experimenting with thin-walled slotted
tubes in an effort to arrive at a design that could be expanded by an angioplasty bal-
loon. The rst human implants of the Palmaz design were performed in 1987. This
revolutionary event set off a technology race that continues today. Since the rst sales
of Palmaz stents in the United States in 1994, the balloon-expandable stent market has
expanded to more than $4 billion per year. To date, the U. S. Food and Drug Admin-
istration has approved 21 balloon-expandable and 28 self-expanding stent designs for
clinical use. Some sample stents that are currently marketed are shown in Figure 1.
The corresponding numbers in European countries are considerably higher.
358 Duraiswamy et al.

Figure 1
Some currently marketed stents: (a) Balloon expansion of a NIR stent, beginning with the
crimped conguration (top), partial expansion with the dog-bone effect shown, and the nal,
expanded conguration (bottom). (b) Release of the self-expanding Wallstent from its catheter.
(c) Expanded congurations of the NIR, Wallstent, and EXPRESS stents shown together,
illustrating the variety in designs and sizes used clinically.
Enthusiasm for stent technology has been somewhat tempered by clinical failures
associated with restenosis. Restenosis in stents occurs due to neointimal hyperplasia
(NIH) through a complex cascade of events, and can take months to develop (see
Figure 2). In bare-metal stent designs, restenosis rates in coronary arteries generally
range from 20%40% (see Table 1) (Kastrati et al. 2001). The earliest reaction
to stent implantation is thrombosis, or the development of a thin layer of a blood
clot due to the presence of a foreign material and the denudation of the naturally
thrombogenic lining of the artery [endothelial cells (ECs)]. In fact, acute thrombosis Restenosis: Clinically
was an often-cited reason for clinical failure of stents until aggressive antithrombotic signicant lumen loss due to
drug regimens could be designed. Thrombosis occurs on the timescale of days, and neointimal hyperplasia after
stenting or angioplasty
begins with the adhesion of blood-borne platelets. The delivery of these cells to the
wall depends heavily on local blood ow patterns, which in turn depend on the stent Neointimal hyperplasia
(NIH): Process of intimal
geometry. Inammation of the artery wall also ramps up within a few days of stent
thickening following
implantation, and includes deposition of blood-borne surface-adherent monocytes interventional procedures
and tissue-inltrating monocytes. Delivery of these cells to the artery wall is also
ECs: Endothelial cells
governed by blood ow patterns.
www.annualreviews.org Stented Artery Flow Patterns 359

Figure 2 Thrombus
Data from Edelman &
Rogers (1998) illustrating
the relative intensity of
different types of vessel
response vs time. In
inammation, the rst
peak represents the Inflammation
heightened activity level
SAMs TIMs
of surface-adherent
monocytes (SAMs) and
the second peak represents

the heightened activity
level of tissue-inltrating
Proliferation
monocytes (TIMs).
Remodeling
7 14 21
Days
Table 1 Summary of binary restenosis rates from Kastrati et al. (2001). Binary
restenosis is defined as 50% or greater diameter stenosis at a 6-month
angiographic follow-up. This clinical study consisted of patients with exclusion
criteria limited to procedural failure and adverse effects within a month of stent
implantation. The total number of patients in which stent design was found to
be a strong independent factor influencing restenosis rates was 4510.
Stent Binary Restenosis Rates
Guidant Multi-Link 20%
Jomed Jostent 25.8%
Johnson & Johnson Palmaz-Schatz 29%
PURA-A 30.9%
Inow Steel 37.3%
NIR 37.8%
Inow Gold 50.3%

Within the rst few weeks of stent implantation, smooth muscle cells (SMCs) that
normally reside in the middle and outer layers of the artery migrate toward the inner
surface. This part of the artery wall response is largely due to the chronic injury caused
SMC: Smooth muscle cells
by the high stress associated with the stent, although it has been shown that endothelial
WSS: Wall shear stress
cells subjected to low wall shear stress (WSS) increase their production of SMC mito-
gens such as endothelin-1 (Yoshizumi et al. 1989). SMCs are important in producing Hemodynamics: Blood
ow dynamics in the
extracellular matrix proteins, which can form a large portion of the volume of NIH.
circulatory system
Arresting SMC proliferation with drugs coated onto stents has resulted in a great re-
Compliance: Level of
duction in coronary in-stent restenosis rates (Morice et al. 2002, Moses et al. 2003).
distensibility of the artery,
If these previous reactions, which all occur to some degree in every stented artery, usually expressed as change
do not result in excessive NIH, it is not likely that the patient will experience clinically in cross-sectional area over
signicant symptoms associated with restenosis. Despite the continued chronic injury change in pressure
to the artery wall caused by nonphysiologic stresses, the artery can adapt to its new
environment through a process clinicians refer to as remodeling, or the geometric
adaptation of the outer layers of the artery. It is important to note that biomechanicians
use this term to refer to the overall adaptation (geometric and material properties) of
tissues to changes in loading conditions.
There is clearly a role for biomechanics in improving on current stent designs.
The artery wall reactions outlined above are mediated by the ow patterns that de-
liver blood-borne cells to the wall, and it has been demonstrated that many artery
wall cellular functions are guided directly or indirectly by the desire of the artery
to maintain WSSs within a certain range (Zarins et al. 1987). This review aims to
summarize the work that has been done to address these uid mechanical aspects.
Reynolds numbers are typically in the range of hundreds for arteries targeted for
stent implantation, but the presence of branches, curvature, and pulsatility leads to
nonlaminar ow patterns. Thus, a variety of computational, experimental, and in vivo
approaches have been employed, and the results demonstrate a strong dependence
on stent design. Interestingly, the effects the stent imposes on hemodynamics can be
observed in locations of the circulatory system quite removed from the stented seg-
ment. There are also important solid mechanical aspects that affect clinical failures of
stents. These are summarized elsewhere (Holzapfel et al. 2005, Moore & Berry 2002).
STENT-INDUCED CHANGES IN OVERALL ARTERIAL

GEOMETRY AND FLOW PATTERNS
The implantation of a stent immediately changes the overall geometry of the vessel.
Large changes in local curvature have been recorded in vivo and are related to ow
patterns that may lead to the eventual development of restenosis. Long term, the most
clinically important stent-induced change in arterial geometry is the development of
NIH, which may result in restenosis. The formation of NIH in stented arteries has
been linked to the persistence of low WSS. Regions of low WSS are also slower to
re-establish the endothelium, which could be important for NIH formation. The
presence of NIH near the stent edges is likely related, at least in part, to ow pat-
terns attributable to the local curvature of the arterial wall and/or the compliance
mismatch.

Figure 3
Three-dimensional reconstruction of a right coronary artery before and after stent

implantation. Stent implantation changes the overall geometry of the artery, typically
straightening the middle section and creating relatively sharp corners at the ends. Taken from
Wentzel et al. (2000).
Curvature changes near stent edges are more important in WSS distribution after
stent placement than local diameter. Wentzel et al. (2000) reconstructed geometries
from seven Wallstents in coronary arteries of Yorkshire pigs using combined angiog-
raphy and intravascular ultrasound (ANGUS) and performed three-dimensional (3D)
ANGUS: Angiography and
intravascular ultrasound computations for WSS distribution. It is important to note that such ow studies have
not accounted for the details of the stent geometry, due to the extremely high com-
putational costs of including such small geometric features. Wall-stent implantation
increased average curvature from the 3D geometry near the entrance by 121% and
near the exit of the stent by 100%. The high gradient in curvature at stent edges (see
Figure 3) resulted in low WSS separation zones downstream. Wentzel et al. (2003)
further extended their imaging methodology to relate WSS to NIH in human coro-
nary arteries as measured with ANGUS (Figure 4). Their results demonstrated an
inverse correlation between mean WSS and intimal thickness for all patients. For the
subset of patients with high blood cholesterol levels, no signicant correlation was
found. On the other hand, the correlation was strengthened in the subset of patients
with normal cholesterol levels compared with the general population.
Lee et al. (2002) analyzed angulation of pre- and postintracoronary stenting from
clinical angiographic data (see Figure 5). Typical curved tube ow patterns such as
high WSS at the outer wall of coronary stenosis and ow recirculation and separation
(low and negative WSS) at the inner wall were greatly reduced due to vessel straight-
ening by the stent. Spatial and temporal variations in WSS were signicantly smaller
in vessels subjected to a higher degree of straightening. Restenosis was greater in pa-
tients whose nal artery geometries were more curved. Phillips et al. (1997) analyzed
121 patients to evaluate lesion angulation on restenosis in Palmaz-Schatz stents. If
the difference in the angle between proximal and distal segments at systole and di-
astole was greater than >15%, it was called a hinge point. Restenosis involved in
lesions having a hinge point was signicantly higher than lesions not having a hinge
point. Angulation of a stented arterial wall may depend on several factors such as
vasodilation, contractility, and rigid implants.

Figure 4
Angiogram of a stented right coronary artery and three-dimensional ANGUS reconstruction
of the right coronary artery showing vessel lumen and wall. At right, color maps of computed
steady shear stress and measured intimal thickness indicate an inverse relationship. Taken from
Wentzel et al. (2003).
EFFECTS OF STENTS ON REGIONAL ARTERIAL

HEMODYNAMICS
Stents have a profound effect on overall ow patterns in the immediate region of the
stent. Large-scale ow disturbances spatially much larger than the geometric features
of the stent have been demonstrated in models of stented arteries. The relative rigidity
of most stents creates a mismatch in mechanical properties between the stented and
immediately adjacent regions. Hemodynamic consequences of compliance mismatch
include increased impedance to ow, decreased distal perfusion, and disturbed ow.
Stents also present a site of pulse wave reections due to the change in mechanical
properties from the relatively rigid stent to the more compliant artery.
Prestent model Poststent model
Model 1 Model 2
Figure 5
Angle change between pre- and postintracoronary stenting models. Model 1 shows a more
curved geometry, where the angle change between pre- and postintracoronary stenting is less
than 50%. Model 2 is a more straight geometry, where the angle change between pre- and
postintracoronary stenting is greater than 50%. Taken from Lee et al. (2002).

Peacock et al. (1995) demonstrated measurable ow disturbances due to stent im-

plantation using an in vitro pulse duplication system. Their model included an aortic
root section and left anterior descending/left circumex coronary artery (LAD/LCX)
LAD: Left anterior
descending coronary artery sections. Slotted Johnson & Johnson, Inc. and Cook spiral stents were implanted in
the LAD section passing over the LCX branch site. Greater downstream LAD ow
LCX: Left circumex
coronary artery instability was observed under exercise conditions, and with the implantation of mul-
tiple stents. These local hemodynamic effects in the downstream LAD were the same
in rigid or exible test sections. Spiral stents with large stent diameter produced more
instabilities than the slotted-tube stents. Large-scale ow disturbances have also been
demonstrated with dye injection ow visualization in compliant tube artery models in
which Palmaz stent models were deployed (Berry et al. 1997). Vortices were seen to
form during ow deceleration, then cleared out with the onset of ow acceleration in
the next cardiac cycle. The formation of ow disturbances upstream or downstream
of stented arteries was quantied in a later study. Yazdani et al. (2004) performed
Doppler particle image velocimetry (DPIV) measurements in rigid cylindrical inserts

and exible Cordis SMART stents upstream and downstream of the stent. In both
stents, two vortices developed upstream as the ow decelerated. As these vortices
diffused, secondary ow phenomena in the form of ring vortices were seen. In the
rigid insert, vortices were larger and had higher residence times compared with the
exible stent.
Rolland et al. (1999) compared the hemodynamics of Palmaz-Schatz, Memotherm,
Wallstent, Symphony, Strecker and Cragg stents in 18 iliac arteries of pigs after
4 days of placement. The pulse ow rate (maximum minimum) was signicantly
diminished in both the treated and contralateral iliac arteries for the more rigid stent
designs (Palmaz, Strecker, Cragg, and Symphony stents). They also noted changes
in artery wall distensibility several diameters upstream of the stent for some designs.
Vernhet et al. (2001) compared the hemodynamic performance of three different
stent designsWallstent, Palmaz-Schatz stents, and Jostentsin the infrarenal artery
of New Zealand white rabbits. They found marked compliance mismatch between
stented and nonstented segments. They postulated that the preferential location of
NIH distally may be explained by compliance mismatch, which could be attributed
to the ow patterns.
Stent implantation induces changes in effective artery wall rigidity that provide
sites for pulse wave reection. Because a stent is typically much smaller than the
wavelengths of the incident waves, these reections are likely to be small. Never-
theless, small changes in regional ow pulsatility may have important physiological
consequences. Formaggia et al. (2002) investigated a one-dimensional (1D) model
of blood ow in a compliant vessel and found that for a constant Youngs modulus
(E) in the stented region, waves get reected from the proximal edge and thereafter
propagate relatively undisturbed. For a spatially varying effective modulus in the
stented region, wave reections within the stent affect the shape of the pressure pulse
in the stented region. So, a stiffer stent or prosthesis results in larger pressure wave
reections at the proximal point, and hence would favor more perturbations in local
hemodynamics. Alderson & Zamir (2004) investigated the hemodynamic effects on a
segmented tube model with varying degrees of stiffness and stent length. A stent near

Figure 6
Physiological-type ow
through a bifurcation model
for four different
congurations at
mid-diastole: (a) without
stent, (b) with a Palmaz
stent, (c) with a nonbevelled
stent model, and (d ) with a
bevelled stent model. Less
ow disturbance was noted
with the bevelled stent.
Taken from Fabregues et al.
(1998).
the entrance has decreased reection effects; a larger stent at the exit has increased
reection effects. They concluded that a short stent placed at the entrance of the
diseased vessel favors less perturbation in local hemodynamics. Overdilated stents
Bifurcation: Regions in
produced less hemodynamic perturbations (Nicoud et al. 2005). circulation where a main
Placement of stents in regions of bifurcations is important for the best possible branch of an artery splits
normalization of ow in all branches. Across an aorto-iliac bifurcation, or carotid into two sub-branches
artery bifurcation, or coronary bifurcation, it is better to place the stent from the Pulsatile: Oscillating or
main branch extending completely into one of the side branches to cause lower ow unsteady (usually periodic)
disturbances in the other side branch (Vernhet et al. 2003). Fabregues et al. (1998) CCA: Common carotid
performed an in vitro investigation of ow modications induced by a Palmaz-Schatz artery
stent placed in the daughter branch of an aorto-iliac bifurcation model with pulsatile ECA: External carotid
ow. In an unstented bifurcation, ow separation occurs at the lateral walls (see artery
Figure 6). With the Palmaz-Schatz stent, stagnation along the lateral walls, ow ICA: Internal carotid artery
separation along the outer wall, and ow recirculation near the apex were seen. With
the bevelled stent, there was no ow perturbation in both daughter vessels and the
vortex at the lateral walls was similar to that produced in the bifurcation without a
stent (see Figure 6). They concluded that the bevelled stent at the bifurcation reduces
ow disturbances in healthy daughter vessels.
Greil et al. (2003) placed Wallstents in silicone models of the carotid artery with
common carotid artery (CCA), external carotid artery (ECA), and internal carotid
artery (ICA). Four models were used: (a) a stent fully in the ICA, (b) a stent extending
from the ICA into the bulb of the CCA (to the tip of the inner wall of the ECA), (c) a
stent extending from the ICA completely into the CCA (blocking ECA), and (d ) a stent
partially extending from the ICA into the bulb of the CCA (see Figure 7). With the
stent fully in the ICA, the velocity prole hardly changed. Velocity increased slightly
within the stented region and a slight decrease in velocity in the separation zone was

Figure 7 Internal carotid

a
(a) Wallstent placed entirely artery (ICA)
in the internal carotid artery Common carotid
(ICA), (b) Wallstent placed artery (CCA)
in the ICA and into the bulb External carotid
of the carotid artery to artery (ECA)
simulate displacement
owing to disproportionate
stent size, (c) Wallstent
b ICA
placed in the common
carotid artery (CCA) and CCA
the ICA, and (d ) Wallstent
placed in the same position ECA
as (a) but positioned 2 mm

backwards in the bulb to
simulate dislocation after c ICA
implantation of an
improperly sized stent. CCA
Taken from Greil et al.
(2003). ECA
d ICA
CCA
ECA
found at the ECA. With a stent extending from the ICA completely into the CCA,
the ow ratio increased, and high velocity uctuations occurred near the inner wall of
the ECA. Velocities at separation zones decreased. The local geometry of the arterial
bifurcations and subsequent stent placement inuence the hemodynamics in that
region. Again, different stent designs have different effects on the local hemodynamics
of bifurcations.
EFFECTS OF STRUT GEOMETRY ON NEAR-WALL

FLOW PATTERNS
Some of the earliest published studies of stent-induced changes in artery wall ow
patterns focused on the near-wall ow patterns, i.e., between the stent struts. Because
stent struts are typically much smaller than the diameters of the arteries, initial studies
were performed with two-dimensional (2D) models, in which the artery wall was
considered a at plate, or in which tubular, axisymmetric ow was modeled. Later, 3D
studies conrmed the general nature of the local ow patterns, although recirculation
zones predicted adjacent to struts in 3D are smaller.
Berry et al. (2000) showed that different stent strut spacing can result in varying
ow patterns such as total recirculation or reattachment between struts or partial reat-
tachment between struts. Their computational uid dynamics (CFD) study showed

Figure 8
Two-dimensional
computational predictions
of streamlines and shear rate
in Wallstents of three
different axial spacings. The
wire crossover points
representing the mesh
design create regions of ow
separation, depending on
the strut spacing. For the
largest strut spacing, the
ow reattaches between the
struts. Taken from Berry

et al. (2000).
presence of stagnation zones both proximal and distal to the stent strut. Stagnation
zones distal to the strut were larger. When the strut wire spacing was the smallest,
there was a single recirculation region between the struts. When the strut wire spac-
ing was more than six wire diameters, uid reattachment between struts occurred for
at least part of the cardiac cycle (see Figure 8). As the strut spacing further increased,
complete ow reattachment between struts during the whole cardiac cycle occurred.
Thus, the stent design, particularly the geometry in this case, inuences the local
hemodynamics and ow patterns in the stented region. These previous studies were
based on the assumption of a rigid artery wall. When comparing rigid and compliant
stented arteries, Henry (2000) showed that in compliant arteries the deection of
the wall depended on the strut spacing: the larger the spacing, the greater the wall
deection. Still, the effects on ow patterns between the struts were minimal.
Fully 3D models of stented artery hemodynamics have generally supported the
results found with 2D models. Benard et al. (2003) mathematically and experimen-
tally modeled the near-wall steady ow patterns produced by a Helistent (Hexacath,
France). Streamlines followed the shape of the strut near the wall. The smallest WSS
was found at the inlet to the stent. They postulated that regions with low WSS (<0.5
Pa) may stimulate SMC proliferation, leading to the formation of NIH. LaDisa et al.
(2004) modeled the hemodynamics of Palmaz-Schatz stents with a stent-to-artery
expansion ratio of 1.1:1 or 1.2:1 under steady ow conditions. Regions of low WSS
were larger with a greater number of struts and with an increase in expansion ratio.
Based on variations in WSS patterns between the different situations (Figure 9), they
concluded that thinner struts and fewer stent intersections may be hemodynamically
advantageous. Low WSS regions were more prevalent at the proximal end of the stent,
possibly making the proximal end more susceptible to NIH. Therefore, geometric
mismatch between stented and nonstented segments of the artery generally contribute
to a major risk of NIH upstream from the stent rather than downstream of the stent.

Figure 9
Computational uid dynamics predictions of wall shear stresses in stented arteries with two
different stent designs and two deployment ratios. Larger areas were subjected to low shear
stress with more struts and with increasing deployment ratio. From LaDisa et al. (2004).
LaDisa et al. (2005) showed via computational modeling that circumferential at-
tening of the artery wall after coronary stent implantation introduced areas of high
WSS or high WSS gradients, absent in circular-stented cross sections under pul-
satile ow conditions. Seo et al. (2005) performed computations on 2D models for
straight vessel segments and 3D models for curved vessel segments for both steady
and unsteady ow. The size of the recirculation zones downstream depended on the
angle of curvature. Flow separation increased with curvature along the outer wall but
decreased with curvature along the inner wall. He et al. (2005) compared detailed
ow characteristics by estimating WSS in the near-strut region of parametric stent
designs using 3D CFD under pulsatile high and low ow conditions. The mean axial
WSS restoration between struts was larger for the stent model with larger interstrut
spacing and for the stent model without longitudinal connectors.
DEMONSTRATED EFFECTS ON ARTERY

WALL RESPONSES: IN VITRO
Based on these model studies, it is reasonable to expect to see differences in artery
wall responses that can be attributed to stent design. While the stent geometry may
be somewhat hidden from ow patterns in the long term due to the formation of
neointima, early responses such as platelet adhesion have been correlated with these

near-wall ow patterns. Platelet adhesion in vitro occurred through the convective

transport of platelets (dened by the streamlines/pathlines) to the wall. Later, en-
dothelization is more rapid in the presence of high WSS conditions. Geometry and the
thickness of the stent struts also affect ow phenomena during re-endothelialization
through stented regions.
Duraiswamy et al. (2005) showed from dynamic ow experiments with a 2D
stented model (consisting of three different strut spacings) that platelet deposition
was higher in areas where ow was directed toward the wall and lower in areas
where ow was directed away from the wall (Figure 10). In 3D stented models, fully
Figure 10
(a) Average normalized platelet deposition between struts of largest spacing plotted as a
function of distance between struts. (b) Path of instantaneous streamlines at minimum ow
(Q = ow rate; nominal shear stress of 10 5 dynes/cm2 ). Platelet deposition patterns
depend on the local ow patterns. Locations A and I dene the corner ow regions very close
to the strut; locations B and H are the center of the recirculation regions; locations C and G
are the points of separation and reattachment (vary up to an order of 0.04 and 0.07 mm,
respectively); location E is a point where the ow is parallel to the bottom wall distal to the
recirculation regions; and locations D and F are points just upstream and downstream of the
separation point and reattachment point, respectively. Taken from Duraiswamy et al. (2005).

Figure 11
Platelet deposition within
the connector region
(from F to G) of a Bx
Velocity stent. Spiral or
helical recirculating ow
exists at all regions around
this connector. Taken
from Duraiswamy (2005).
separated regions of recirculation both proximal and distal to the strut were very
small and exhibited very low platelet deposition (Duraiswamy 2005). The spirally
recirculating regions near stent strut connectors had more complex uid dynam-
ics and, hence, more platelet deposition than the fully separated recirculation re-
gions proximal or distal to the strut (Figure 11). Circumferentially along the
wall, alternate regions of higher and lower platelet deposition were found. Thus,
platelet deposition primarily depends on the near-wall ow patterns in a stented
region.
Sukavaneshvar et al. (2000) studied thrombus and emboli formation in the pres-
ence of a stenosis upstream or downstream of a stent. They used bovine holstein
heparinized blood driven by gravity through a conduit containing a stent. Embolism
was higher with stenoses than with nonstenosis controls. Increased thrombus resulted
in increased emboli, but not vice versa. Thrombus was favored by increased radial
transport, increased recirculation, and low shear stress. The formation of emboli was
favored by elevated radial transport and high shear stress.
The re-establishment of the endothelium is also affected by the ow phenomena
associated with strut conguration. Sprague et al. (1997) showed that endothelial
cell migration onto metal surfaces from a surrounding gel covered with a conuent
monolayer of cells was inuenced by WSS. When relatively high shear was imposed
(15 dynes/cm2 ), endothelial cell migration onto the metal surface was relatively rapid,
with a signicantly higher migration rate measured from the upstream edge. Under
low shear conditions (2 dynes/cm2 ), migration onto the metal surface was slow, and
showed no preferred direction. Simon et al. (2000) showed that EC migration on
top of the stent struts was faster with struts of 75 m thickness than struts with a
thickness of 250 m under physiologic ow conditions (WSS = 12 dynes/cm2 ). In
cases where the sides of the struts were aligned with the ow direction, endothelial
coverage was complete, as compared with the downstream edge, where endothelial
monolayer retreat was noted.

DEMONSTRATED EFFECTS ON ARTERY WALL

RESPONSES: IN VIVO ANIMAL EXPERIMENTS
The ability to implant stents in appropriately sized animal arteries creates additional
capabilities to observe the stent/artery interaction that cannot be achieved with
in vitro or clinical studies. Most animal studies show an inverse relationship
between WSS and NIH. In the regions of bifurcations, the NIH in stented
parent vessels with occluded side branches is controlled by side branch ow.
Animal studies also indicate the importance of endothelization in controlling
NIH. Here again, the importance of ow dynamics within the stented region is
illustrated.
Newman et al. (1996) implanted prototype stents in the left iliac artery and a
Palmaz-Schatz stent in the contralateral iliac artery of dogs to demonstrate the

in vivo response. The prototype stent was an open design and hence may exhibit
more compliance and less stagnation under pulsatile ow. Flow visualization showed
the dye stagnating near the struts correlating to NIH in these regions; dye was washed
away sooner in the prototype stent due to exposure of vessel wall to pulse pressure.
Carter et al. (2005) implanted 16 stents [bare metal and Sirolimus (SRL) Bx velocity
stents] in miniswine coronary artery. At 30 days, NIH was less in SRL than in the
bare metal stent. At 90 days, the mean NIH area was similar for both. Carter et al.
concluded that an inverse relationship existed between WSS and NIH for the bare
metal stent, whereas a positive relationship between WSS and NIH existed for the
SRL stent (see Figure 12). The SRL stent appeared less effective at NIH suppression
in regions of high WSS.
Richter et al. (2000) injected In-111 labeled platelets in 24 canines to study platelet
activity. Stents were placed in femoral arteries after ligation of side branches to cause
restricted ow conditions. Restricted ow conditions led to increased thrombotic
responses without anticoagulation and greater NIH thickness over the struts; at
Figure 12
Correlations between the histological neointimal area (mm2 ) at 90 days and normalized
segmental vessel wall shear stress (SS) immediately poststent deployment from matched cross
sections of the sirolimus-eluting (a) and bare-metal (b) stents. Taken from Carter et al. (2005).

24 weeks mean NIH in ow-restricted stents was less, indicating a late enlargement
of the stent lumen. Sukavaneshvar et al. (2000) developed an ovine arterio-arterial
ex vivo shunt model to study thrombus and emboli formation with stents. Increased
ow rate caused increased emboli formation. Pulsatile ow caused more emboli and
thrombi formation than steady ow.
Palmaz et al. (1988) implanted 10 albino rabbits with abdominal stents. At 72 h,
there was evidence of EC growth. At 1 week, the entire surface was covered with
EC (swirling pattern near struts, mosaic pattern between struts). They proposed that
re-endothelization may occur by lateral growth of the surviving endothelium. En-
dothelial cells on grafts may appear to come from circulating cells, possibly endothelial
progenitor cells (Scott et al. 1994).
Richter et al. (2004) studied ow patterns in a generalized large artery (i.e., ilio-
femoral) bifurcation to relate ow disturbance with NIH in a porcine model of bifur-
cation stenting. The in vivo model featured side branch occlusion at different time
points prior to stent implantation so that main branch adaptation could be varied (see
Figure 13). In one set of animals, the main branch stents were placed after 28 days
(presumably after adaptation or remodeling to the new ow environment), whereas
in another set, main branch stents were placed after 3 days. In vivo, NIH formed in
the separated ow regions and then was reduced back to normal distally along the
length of the stent. Leukocyte recruitment was larger in the areas of ow separation,
which were most prevalent with a patent side branch (Figure 13). In animals where
main branch remodeling was allowed, intimal response was most pronounced at the
ends and lesser in the middle of the stented region, with less NIH in the main branch
when the side branch was occluded. In animals where main branch remodeling was
not allowed, NIH did not depend on the state of the side branch. Thus, in the re-
gions of bifurcations, restenosis in stented parent vessels with occluded side branches
is affected by side branch ow.
CLINICAL STUDIES
Limitations on obtaining exact stented artery geometry and ow waveforms constrain
the ability to study in vivo hemodynamics. Still, clinical studies indicate that NIH is
greater in regions of low WSS. It is important to recognize the complex interplay
between hemodynamics and NIH formation over time. Both processes have an effect
on one another: They form a dynamic feedback loop that is difcult to observe
in vivo. Therefore, in vivo studies should be viewed carefully with regard to time
points. Most of the clinical studies show the inverse relationship between NIH and
WSS to hold at least until 12 months postimplantation. There is also contradictory
evidence that NIH is higher at the proximal end in some studies, whereas in others
NIH is low at both stent edges.
Wentzel et al. (2001) showed that NIH from 14 patients after coronary Wallstent
implantation was inversely related to WSS at a 6-month follow-up. Gijsen et al.
(2003) performed a clinical study in which six patients (from the RAVEL trial) were
implanted with SRL Bx velocity stents in a coronary artery. Six months after the
implant the mean NIH was greater in the regions of low WSS. Overall, it was seen

Figure 13
a
(a) Unilateral occlusion of
the side branches of the
Side porcine ilio-femoral
branch (SB) bifurcation was performed
occlusion
as described. (b) The main
branches were then stented
Main bilaterally with or without
branch (MB) allowing the main branch
stents time to adapt to side branch
occlusion. (c) After chronic
follow-up, main branch
stents were analyzed for
neointimal hyperplasia and

inammatory cell
recruitment. With patent
side branches, more

separation occurred in the
main branch, and
b inammatory cell
SB occlusion MB stenting Sacrifice recruitment into the stented
Group A region was higher. Taken
(remodeling) 28 d 28 d from Richter et al. (2004).
Group B 3d 28 d
(no remodeling)
SB occlusion MB stenting Sacrifice
c 14
Leukocytes (lateral wall)/
leukocytes (flow divider)
12
SB patent
10 SB occluded
0
1 2 3 4 5 6 7
Section number (proximal to distal)
that NIH is inversely related to WSS. In this study, the inverse relationship between
NIH and WSS was contradictory to the linear relationship between NIH and WSS
in Carter et al. (2005), although both studies used SRL-eluting stents. However, the
Carter et al. (2005) study had a follow-up period of only 90 days, whereas the Gijsen
et al. (2003) study had a follow-up period of 6 months.

Stone et al. (2003) performed a clinical study with eight patients (native and stented
arteries) who had already undergone stent deployment, had another coronary artery
with 25% to 50% luminal obstruction, and had a history of arterial hypertension. In
DES: Drug-eluting stent
the native artery, regions of pathologically low baseline WSS developed progressive
PBS: Phosphate-buffered
atherosclerosis with outward or positive remodeling. Regions of increased baseline
saline
WSS exhibited outward remodeling. In stented portions, NIH forms, resulting in a
decrease in lumen radius and an increase in WSS regardless of the level of baseline
WSS. Garcia et al. (2006) performed a follow-up study after stent implantation in
the middle-right coronary artery in patients where WSS and NIH was lower at the
stent edges compared with the intrastent region.
DRUG MASS TRANSFER

The recent emergence of drug-eluting stents (DESs) has led to considerable interest in
the spatial variation in artery wall drug concentrations as they depend on stent geom-
etry, drug characteristics, and artery wall architecture. Some drugs such as paclitaxel
are hydrophobic, whereas others such as heparin are hydrophilic. The hydrophobicity
of the drug plays an important role in its transfer characteristics, which may be dom-
inated by diffusion or convection. Hydrophilic drugs are washed away more quickly
due to their tendency to follow transmural uid movement. Hydrophobic drugs can
attain higher concentrations in the artery wall due to their preferential binding to
artery wall structural proteins. The molecular weight of the drug also plays a role,
as does the rate of uptake by cells in the artery wall. The natural layered structure
of the artery wall complicates the analysis of drug mass transfer. The roughly cir-
cumferential arrangement of the artery wall lamellae results in nonisotropic diffusion
characteristics. The result is a richly interesting problem that has been addressed
with various approaches. Computational studies predict that homogeneity in drug
deposition is strongly affected both circumferentially and longitudinally by the stent
strut spacing as well as other design parameters. The drug distribution in the artery
wall between the stents can also be inuenced by the uid dynamics of a specic stent
design.
Hwang et al. (2001) used Palmaz-Schatz stents spray-coated with 33% uores-
cein sodium dissolved in dichloromethane, deployed in cannulated bovine carotid
arteries, and circulated in a phosphate-buffered saline (PBS) solution. The artery
was sliced to measure the uorescein concentration. Zones of high and low con-
centrations throughout the media followed the stent geometry. Such changes are
present in both the longitudinal and circumferential directions. High drug zones
were present near stent struts, whereas low drug zones appeared near interstrut spac-
ing. Mongrain et al. (2005) numerically modeled drug delivery to study the inuence
of geometry, stent conguration, eluting polymer coating thickness, and initial doses,
assuming homogenous isotropic nonporous media, rigid structure, and steady ow.
Drug retention was higher for thicker polymer coating. With an increase in interstrut
distance, homogeneity in drug distribution decreased and drug retention in polymer
and arterial wall decreased. Drug retention in the polymer and the arterial wall was
affected by the degree of embedding of the stent into the arterial wall. In either case,

there is a trade-off on interstrut distance and degree of embedding. Balakrishnan

et al. (2005) coupled CFD and mass transfer in a model applied to predict drug depo-
sition for single and overlapping DESs. Direct contact of DES with an arterial wall
accounts for only 38% of peak and 11% of total arterial drugs. Overall tissue uptake
was determined by the drug sources in direct contact with tissue- and ow-mediated
convective transport of drug pools into the arterial wall. Drug deposition increased
when struts were placed further apart. When struts overlapped, drug deposition was
much higher in the stagnation zones (see Figure 14) where brin deposition was
higher, thus altering vascular healing. Strut geometry had minimal effect on drug
deposition proximal and distal to the strut, especially at recirculation regions.
Figure 14
a 0.75
(a) Arterial drug
concentrations for single
drug-eluting stent (DES)

strut and different
[Arterial drug]
congurations of two DESs.

0.5
(b) Arterial drug
concentrations when top
strut is staggered
proximal/upstream to
bottom strut, in which
0.25 either one or two struts are
drug eluting. Boxes
illustrate specic strut
conguration; drug coating
0 Region beneath single strut is designated by colored
strut sides. Concentration
-8 Proximal 0 8 Distal 16 proles (colored according
Longitudinal distance (strut lengths) to drug-coated surfaces) as a
function of axial distance
along the arterial wall were
b 0.75 taken at a depth of 1.5 strut
lengths into the arterial
wall. Taken from
Balakrishnan et al. (2005).
[Arterial drug]
0.5
Strut not
loaded
with drug
0.25
0 Region beneath single strut

-8 Proximal 0 8 Distal 16
Longitudinal distance (strut lengths)

SUMMARY AND CONCLUSIONS

There have been a variety of approaches employed to provide a better understanding
of stented artery hemodynamics and the inuence on NIH formation and restenosis.
Because of the small size of stent struts, computational techniques are particularly
useful for predicting near-wall phenomena. Experimental techniques can also be used,
whether in a scaled-up fashion, or to observe large-scale changes in ow patterns.
In vitro experiments with cells or actual blood have been extremely useful in under-
standing how ow patterns may inuence individual reactions of the artery wall to the
stent. Animal studies have demonstrated the effects of stent placement on overall ow
patterns such as ow pulsatility. Finally, modern imaging techniques, e.g., ANGUS,
have been used to provide realistic arterial geometries for computational models, and
to quantify the spatial distribution of NIH. As more sophisticated imaging modalities

become available (optical coherence tomography appears particularly promising), the
ability to correlate specic hemodynamic phenomena with NIH should be enhanced.

However, it is important to recognize that access to extensive clinical data is limited
by the danger of repeated invasive procedures. Thus, there is still an important role
for modeling, along with in vitro and animal experiments, in understanding clinical
failures of stents.
Stents affect blood ow patterns at different levels. The ow and pressure wave-
forms are affected by the essentially rigid insert in an otherwise compliant tube system.
Locally, changes in geometry due primarily to the straightening of curved arteries
can profoundly affect blood ow patterns. At the submillimeter level, near-wall ow
stagnation and WSS are extremely sensitive to stent strut spacing and overall mesh
design. In vitro experiments have demonstrated that platelet adhesion and endothe-
lial cell regrowth are clearly affected by these small-scale ow phenomena. To date,
no one has directly investigated the effects of these ow patterns on inammation or
SMC proliferation. A direct link to clinical observations of restenosis is difcult to
nd due to the many factors that inuence restenosis formation. Furthermore, no two
atherosclerotic lesions are alike: Some are more rigid, featuring brotic caps or cal-
cications, and some are softer due to high lipid content. Although this complicates
the direct application of previous modeling efforts, it also provides an opportunity
for clinicians and engineers to work together to design lesion-specic stents that
minimize the risk of restenosis in a particular situation.
The efcient transfer of drugs into the artery wall provides another interesting
opportunity for modelers. However, there are numerous challenges. As mentioned
above, drugs can have different characteristics that inuence their transfer into the
artery wall (hydrophobicity, molecular weight, etc.). The artery wall can also exhibit
nonisotropic convection and diffusion characteristics. Furthermore, the presence of
the atherosclerotic plaque can generate signicant nonhomogeneities in mass trans-
fer characteristics. Such properties have never been quantied, but must be at least
estimated if functional, clinically relevant models are to be developed. There is also a
very basic question regarding the desired drug delivery prole. It has been proposed
that drug delivery to the artery wall should be uniform. However, stresses in the
artery wall and thus local damage and injury response are highly nonuniform. The

formation of NIH is also nonuniform. The desire for uniform drug delivery is thus
based on assumptions yet to be proven in any meaningful way.
While DESs have been successful at limiting restenosis in coronary arteries, there
remain several challenges associated with other areas of the circulation. In particular,
preventing restenosis in the arteries of the legs has proven challenging. Restenosis
rates for drug-eluting or bare-metal stents deployed in the femoral arteries, for exam-
ple, remain well above 30%nearly double that for lesions longer than 7 cm (Duda
et al. 2002, 2005). The physiologic situation in peripheral arteries is quite different
from that in coronary arteries. The arteries of the legs, for example, feature ow
waveforms that oscillate strongly between forward and retrograde ow. Distal runoff
can also be poor, leading to low mean ow rates. These factors result in arteries of
the legs being subjected to low and oscillating WSS, conditions that have been linked
to early, focal atherosclerosis development in every commonly diseased arterial seg-
ment (He & Ku 1996, Ku et al. 1985, Moore et al. 1994). There is also evidence that
low and oscillating WSS correlates with intimal hyperplasia development in bypass
graft anastomoses (Rhee & Tarbell 1994). There are also unique solid mechanical
challenges in the leg arteries that result from the large deformations that occur due
to limb movements such as hip and knee exion (Cheng et al. 2005). These defor-
mations have been linked to fractures of stent struts and associated clinical failures.
Thus, it could be said that procedures to treat atherosclerosis in the arteries of the
legs are especially challenged, relative to coronary procedures. This, along with the
clinical evidence that current DES do not perform well in peripheral applications,
suggests that alternative strategies are required. The use of other materials, such as
biodegradable polymers or metals, provides interesting possibilities.
The development of stent technology has provided an interesting case study of
implant-tissue interaction involving complex biomechanics. The prevalence of these
devices in the market has the potential to provide important histological informa-
tion on failure mechanisms (Virmani et al. 2002, Virmani & Farb 1999). Advances in
technology, including better machining capabilities, drug development, and materials
characterization have greatly reduced restenosis rates. As we continue to enhance our
understanding of stent-artery interactions and biomechanics, even greater improve-
ments in patient care can be expected.
SUMMARY POINTS
1. We have summarized a variety of approaches for understanding stented
artery hemodynamics and formation of NIH and restenosis.
2. Ability to correlate hemodynamic phenomena with NIH needs to be en-
hanced, hence there exists a role for in vitro and animal modeling.
3. Stent design affects ow mechanics at different levels.
4. Hemodynamics in peripheral arteries are complex and current methodolo-
gies are insufcient in minimizing restenosis.

5. Further understanding of stent-tissue interaction is required and there is

still a role for biomechanics in stent design to reduce restenosis rates.
FUTURE ISSUES
1. Alternate strategies such as biodegradable polymer stents are required for
peripheral artery stent implantations.
2. Optimal drug delivery methods should be pursued to minimize restenosis
with DESs.
3. Further research on stent-tissue interaction to study the role of primary
chemotactic agents that triggers each step in restenosis is necessary.
ACKNOWLEDGMENTS
The authors are partially funded by a grant from the National Institutes of Health
Minority Biomedical Research Support for Support of Continuous Research Excel-
lence (S06 GM08205) at Florida International University and a grant from the Na-
tional Institutes of Health (R01 EB000115) at Texas A&M University. The authors
apologize for the omission of some relevant publications due to space limitations.
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cells. Biochem. Biophy. Res. Commun. 161(2):85964
Zarins CK, Zatina MA, Giddens DP, Ku DN, Glagov S. 1987. Shear stress regulation
of artery lumen diameter in experimental atherogenesis. J. Vas. Surg. 5(3):413
20

Contents ARI 11 November 2006 9:35
Annual Review of
Contents Fluid Mechanics
Volume 39, 2007
H. Julian Allen: An Appreciation

Walter G. Vincenti, John W. Boyd, and Glenn E. Bugos p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Osborne Reynolds and the Publication of His Papers

on Turbulent Flow
Derek Jackson and Brian Launder p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p18

Hydrodynamics of Coral Reefs
Stephen G. Monismith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p37
Internal Tide Generation in the Deep Ocean
Chris Garrett and Eric Kunze p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p57
Micro- and Nanoparticles via Capillary Flows
Antonio Barrero and Ignacio G. Loscertales p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p89
Transition Beneath Vortical Disturbances
Paul Durbin and Xiaohua Wu p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 107
Nonmodal Stability Theory
Peter J. Schmid p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 129
Intrinsic Flame Instabilities in Premixed and Nonpremixed
Combustion
Moshe Matalon p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 163
Thermouid Modeling of Fuel Cells
John B. Young p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 193
The Fluid Dynamics of Taylor Cones
Juan Fernndez de la Mora p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 217
Gravity Current Interaction with Interfaces
J. J. Monaghan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 245
The Dynamics of Detonation in Explosive Systems
John B. Bdzil and D. Scott Stewart p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 263
The Biomechanics of Arterial Aneurysms
Juan C. Lasheras p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 293
vii
Contents ARI 11 November 2006 9:35
The Fluid Mechanics Inside a Volcano

Helge M. Gonnermann and Michael Manga p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 321
Stented Artery Flow Patterns and Their Effects on the Artery Wall
Nandini Duraiswamy, Richard T. Schoephoerster, Michael R. Moreno,
and James E. Moore, Jr. p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 357
A Linear Systems Approach to Flow Control
John Kim and Thomas R. Bewley p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 383
Fragmentation
E. Villermaux p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 419
Turbulence Transition in Pipe Flow
Bruno Eckhardt, Tobias M. Schneider, Bjorn Hof, and Jerry Westerweel p p p p p p p p p p p p p p p p 447
Waterbells and Liquid Sheets

Christophe Clanet p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 469
Indexes
Subject Index p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 497

Cumulative Index of Contributing Authors, Volumes 139 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 511
Cumulative Index of Chapter Titles, Volumes 139 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 518
Errata
An online log of corrections to Annual Review of Fluid Mechanics chapters

(1997 to the present) may be found at http://uid.annualreviews.org/errata.shtml
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ANRV294-FL39-15 ARI 12 December 2006 6:5

Stented Artery Flow

Annu. Rev. Fluid Mech. 2007. 39:35782 Key Words

358 Duraiswamy et al.

www.annualreviews.org Stented Artery Flow Patterns 359

the second peak represents

360 Duraiswamy et al.

STENT-INDUCED CHANGES IN OVERALL ARTERIAL

www.annualreviews.org Stented Artery Flow Patterns 361

Three-dimensional reconstruction of a right coronary artery before and after stent

362 Duraiswamy et al.

EFFECTS OF STENTS ON REGIONAL ARTERIAL

Prestent model Poststent model

www.annualreviews.org Stented Artery Flow Patterns 363

Peacock et al. (1995) demonstrated measurable ow disturbances due to stent im-

Doppler particle image velocimetry (DPIV) measurements in rigid cylindrical inserts

364 Duraiswamy et al.

www.annualreviews.org Stented Artery Flow Patterns 365

Figure 7 Internal carotid

as (a) but positioned 2 mm

EFFECTS OF STRUT GEOMETRY ON NEAR-WALL

366 Duraiswamy et al.

struts. Taken from Berry

www.annualreviews.org Stented Artery Flow Patterns 367

DEMONSTRATED EFFECTS ON ARTERY

368 Duraiswamy et al.

near-wall ow patterns. Platelet adhesion in vitro occurred through the convective

www.annualreviews.org Stented Artery Flow Patterns 369

370 Duraiswamy et al.

DEMONSTRATED EFFECTS ON ARTERY WALL

Palmaz-Schatz stent in the contralateral iliac artery of dogs to demonstrate the

www.annualreviews.org Stented Artery Flow Patterns 371

372 Duraiswamy et al.

neointimal hyperplasia and

side branches, more

www.annualreviews.org Stented Artery Flow Patterns 373

DRUG MASS TRANSFER

374 Duraiswamy et al.

there is a trade-off on interstrut distance and degree of embedding. Balakrishnan

drug-eluting stent (DES)

congurations of two DESs.

0 Region beneath single strut

Longitudinal distance (strut lengths)

www.annualreviews.org Stented Artery Flow Patterns 375

SUMMARY AND CONCLUSIONS

to quantify the spatial distribution of NIH. As more sophisticated imaging modalities

ability to correlate specic hemodynamic phenomena with NIH should be enhanced.

376 Duraiswamy et al.

www.annualreviews.org Stented Artery Flow Patterns 377

5. Further understanding of stent-tissue interaction is required and there is

chemotactic agents that triggers each step in restenosis is necessary.

378 Duraiswamy et al.

an experimental and computational approach. PhD thesis, Florida Intl. Univ.

Fabregues S, Baijens K, Rieu R, Bergeron P. 1998. Hemodynamics of endovascular

www.annualreviews.org Stented Artery Flow Patterns 379

of coronary circulation in angulated coronary stenosis following stenting. Yonsei

Mongrain R, Leask R, Brunette J, Faik I, Bulman-Feleming N, Nguyen T. 2005.

380 Duraiswamy et al.

Richter Y, Groothuis A, Seifert P, Edelman ER. 2004. Dynamic ow alterations

www.annualreviews.org Stented Artery Flow Patterns 381

382 Duraiswamy et al.

Contents Fluid Mechanics

Volume 39, 2007

H. Julian Allen: An Appreciation