Effects of longitudinal pre-stretch on the mechanics of human aorta before and after thoracic endovascular aortic repair (TEVAR) in trauma patients

  • Anastasia DesyatovaEmail author
  • Jason MacTaggart
  • Alexey Kamenskiy
Original Paper


Thoracic endovascular aortic repair (TEVAR) has evolved as a first-line therapy for trauma patients. Most trauma patients are young, and their aortas are compliant and longitudinally pre-stretched. We have developed a method to include longitudinal pre-stretch in computational models of human thoracic aortas of different ages before and after TEVAR. Finite element models were built using computerized tomography angiography data obtained from human subjects in 6 age groups 10–69 years old. Aortic properties were determined with planar biaxial testing, and pre-stretch was simulated using a series of springs. GORE C-Tag stent-graft was computationally deployed in aortas with and without pre-stretch, and the stress–strain fields were compared. Pre-stretch had significant qualitative and quantitative effects on the aortic stress–strain state before and after TEVAR. Before TEVAR, mean intramural aortic stresses with and without pre-stretch decreased with age from 108 kPa and 83 kPa in the youngest age group, to 60 kPa in the oldest age group. TEVAR increased intramural stresses by an average of 73 ± 15 kPa and 48 ± 10 kPa for aortas with and without pre-stretch and produced high stress concentrations near the aortic isthmus. Inclusion of pre-stretch in young aortas increased intramural stresses by 30%, while in > 50-year-old subjects it did not change the results. Computational modeling of aorta-stent-graft interaction that includes pre-stretch can be instrumental for device design and assessment of its long-term performance, and in the future may help more accurately determine the stress–strain characteristics associated with TEVAR complications.


Pre-stretch Aorta Computational modeling Thoracic endovascular aortic repair Stent-graft 



The authors wish to acknowledge Live On Nebraska for their help and support and thank tissue donors and their families for making this study possible.


Research reported in this publication was supported in part by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Numbers HL124905, HL147128, and HL125736.

Compliance with ethical standards

This manuscript does not study living human or animal subjects. Cadaveric specimens were obtained after receiving consent from next of kin.

Conflict of interest

Authors declare that they have no conflict of interest.


  1. Arthurs ZM, Starnes BW, Sohn VY et al (2009) Functional and survival outcomes in traumatic blunt thoracic aortic injuries: an analysis of the National Trauma Databank. J Vasc Surg 49:988–994. CrossRefGoogle Scholar
  2. Atkins MD, Marrocco CJ, Bohannon WT, Bush RL (2009) Stent-graft repair for blunt traumatic aortic injury as the new standard of care: is there evidence? J Endovasc Ther 16(Suppl 1):I53–I62. Google Scholar
  3. Bellini C, Ferruzzi J, Roccabianca S et al (2014) A microstructurally motivated model of arterial wall mechanics with mechanobiological implications. Ann Biomed Eng 42:488–502. CrossRefGoogle Scholar
  4. Burdess A, Mani K, Tegler G, Wanhainen A (2018) Stent-graft induced new entry tears after type B aortic dissection: how to treat and how to prevent? J Cardiovasc Surg (Torino) 59:789–796. Google Scholar
  5. Bussmann A, Heim F, Delay C et al (2017) Textile aging characterization on new generations of explanted commercial endoprostheses: a preliminary study. Eur J Vasc Endovasc Surg. Google Scholar
  6. Canaud L, Gandet T, Sfeir J et al (2019) Risk factors for distal stent graft-induced new entry tear after endovascular repair of thoracic aortic dissection. J Vasc Surg. Google Scholar
  7. Cheng D, Martin J, Shennib H et al (2010) Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 55:986–1001CrossRefGoogle Scholar
  8. Cocciolone AJ, Hawes JZ, Staiculescu MC et al (2018) Elastin, arterial mechanics, and cardiovascular disease. Am J Physiol Circ Physiol. Google Scholar
  9. Cuomo F, Roccabianca S, Dillon-Murphy D et al (2017) Effects of age-associated regional changes in aortic stiffness on human hemodynamics revealed by computational modeling. PLoS ONE 12:e0173177. CrossRefGoogle Scholar
  10. Demanget N, Avril S, Badel P et al (2012) Computational comparison of the bending behavior of aortic stent-grafts. J Mech Behav Biomed Mater 5:272–282. CrossRefGoogle Scholar
  11. Demanget N, Duprey A, Badel P et al (2013) Finite element analysis of the mechanical performances of 8 marketed aortic stent-grafts. J Endovasc Ther 20:523–535. CrossRefGoogle Scholar
  12. Evans JA, van Wessem KJP, McDougall D et al (2010) Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg 34:158–163. CrossRefGoogle Scholar
  13. Ferruzzi J, Di Achille P, Tellides G, Humphrey JD (2018) Combining in vivo and in vitro biomechanical data reveals key roles of perivascular tethering in central artery function. PLoS ONE 13:1–21. CrossRefGoogle Scholar
  14. Figueroa CA, Taylor CA, Yeh V et al (2009) Effect of curvature on displacement forces acting on aortic endografts: a 3-dimensional computational analysis. J Endovasc Ther 16:284–294CrossRefGoogle Scholar
  15. Fung GSK, Lam SK, Cheng SWK, Chow KW (2008) On stent-graft models in thoracic aortic endovascular repair: a computational investigation of the hemodynamic factors. Comput Biol Med 38:484–489. CrossRefGoogle Scholar
  16. Gonçalves FB, Ultee KHJ, Hoeks SE et al (2016) Life expectancy and causes of death after repair of intact and ruptured abdominal aortic aneurysms Presented in the Plenary Rapid Pace Session at the 2015 Vascular Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, June 17–20, 2015. J Vasc Surg 63:610–616. CrossRefGoogle Scholar
  17. Goyal VK (1982) Changes with age in the aorta of man and mouse. Exp Gerontol 17:127–132. CrossRefGoogle Scholar
  18. Hartford JM, Fayer RL, Shaver TE et al (1986) Transection of the thoracic aorta: assessment of a trauma system. Am J Surg 151:224–229CrossRefGoogle Scholar
  19. Haskett D, Johnson G, Zhou A et al (2010) Microstructural and biomechanical alterations of the human aorta as a function of age and location. Biomech Model Mechanobiol 9:725–736. CrossRefGoogle Scholar
  20. Herrera CMG, Celentano DJ, Cruchaga MA et al (2010) Mechanical characterization of the human thoracic descending aorta Experiments and modelling. Comput Methods Biomech Biomed Eng 15:185–193CrossRefGoogle Scholar
  21. Holzapfel Ga, Gasser TC (2007) Computational stress-deformation analysis of arterial walls including high-pressure response. Int J Cardiol 116:78–85. CrossRefGoogle Scholar
  22. Holzapfel GA, Gasser TC, Ogden RW (2000) A new constitutive framework for arterial wall mechanics and a comparative study of material models. J Elast 61:1–48MathSciNetCrossRefzbMATHGoogle Scholar
  23. Horny L, Adamek T, Gultova E et al (2011) Correlations between age, prestrain, diameter and atherosclerosis in the male abdominal aorta. J Mech Behav Biomed Mater 4:2128–2132. CrossRefGoogle Scholar
  24. Horny L, Adamek T, Kulvajtova M (2013) Analysis of axial prestretch in the abdominal aorta with reference to post mortem interval and degree of atherosclerosis. J Mech Behav Biomed Mater. Google Scholar
  25. Horný L, Netušil M, Voňavková T (2013) Axial prestretch and circumferential distensibility in biomechanics of abdominal aorta. Biomech Model Mechanobiol 13:783–799. CrossRefGoogle Scholar
  26. Horný L, Adámek T, Kulvajtová M (2016) A comparison of age-related changes in axial prestretch in human carotid arteries and in human abdominal aorta. Biomech Model Mechanobiol. Google Scholar
  27. Hughes GC (2019) Stent graft–induced new entry tear (SINE): intentional and NOT. J Thorac Cardiovasc Surg 157:101.e3–106.e3. CrossRefGoogle Scholar
  28. Humphrey JD (2012) Possible mechanical roles of glycosaminoglycans in thoracic aortic dissection and associations with dysregulated transforming growth factor-β. J Vasc Res 50:1–10. CrossRefGoogle Scholar
  29. Humphrey JD, Eberth JF, Dye WW, Gleason RL (2009) Fundamental role of axial stress in compensatory adaptations by arteries. J Biomech 42:1–8. CrossRefGoogle Scholar
  30. Jadidi M, Desyatova A, MacTaggart J, Kamenskiy A (2019) Mechanical stresses associated with flattening of human femoropopliteal artery specimens during planar biaxial testing and their effects on the calculated physiologic stress–stretch state. Biomech Model Mechanobiol Accepted. Google Scholar
  31. Jonker FHW, Schlosser FJV, Geirsson A et al (2010) Endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther 17:725–734. CrossRefGoogle Scholar
  32. Kamenskiy A, Pipinos I, Dzenis Y et al (2014a) Passive biaxial mechanical properties and in vivo axial pre-stretch of the diseased human femoropopliteal and tibial arteries. Acta Biomater 10:1301–1313. CrossRefGoogle Scholar
  33. Kamenskiy AVA, Dzenis YYA, Kazmi SAJSAJ et al (2014b) Biaxial mechanical properties of the human thoracic and abdominal aorta, common carotid, subclavian, renal and common iliac arteries. Biomech Model Mechanobiol 13:1341–1359. CrossRefGoogle Scholar
  34. Kamenskiy A, Miserlis D, Adamson P et al (2015) Patient demographics and cardiovascular risk factors differentially influence geometric remodeling of the aorta compared with the peripheral arteries. Surgery. Google Scholar
  35. Kamenskiy A, Seas A, Bowen G et al (2016) In situ longitudinal pre-stretch in the human femoropopliteal artery. Acta Biomater 32:231–237. CrossRefGoogle Scholar
  36. Kamenskiy A, Seas A, Deegan P et al (2017) Constitutive description of human femoropopliteal artery aging. Biomech Model Mechanobiol 16:681–692. CrossRefGoogle Scholar
  37. Kleinstreuer C, Li Z, Basciano CA et al (2008) Computational mechanics of Nitinol stent grafts. J Biomech 41:2370–2378CrossRefGoogle Scholar
  38. Learoyd BM, Taylor MG (1966) Alterations with age in the viscoelastic properties of human arterial walls. Circ Res 18:278–292. CrossRefGoogle Scholar
  39. Li Z, Kleinstreuer C, Farber M (2005) Computational analysis of biomechanical contributors to possible endovascular graft failure. Biomech Model Mechanobiol 4:221–234. CrossRefGoogle Scholar
  40. Ma T, Dong ZH, Wang S et al (2018) Computational investigation of interaction between stent graft and aorta in retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection. J Vasc Surg 68:14S–21S. CrossRefGoogle Scholar
  41. MacTaggart JNJN, Poulson WEWE, Akhter M et al (2016) Morphometric roadmaps to improve accurate device delivery for fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 80:941–946. CrossRefGoogle Scholar
  42. Miller LE (2012) Potential long-term complications of endovascular stent grafting for blunt thoracic aortic injury. Sci World J 2012:897489. CrossRefGoogle Scholar
  43. Mithieux SM, Weiss AS (2005) Elastin. Adv Protein Chem 70:437–461. CrossRefGoogle Scholar
  44. Muhs BE, Balm R, White GH, Verhagen HJM (2007) Anatomic factors associated with acute endograft collapse after Gore TAG treatment of thoracic aortic dissection or traumatic rupture. J Vasc Surg 45:655–661. CrossRefGoogle Scholar
  45. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ (1958) Nonpenetrating traumatic injury of the aorta. Circulation 17:1086–1101. CrossRefGoogle Scholar
  46. Pasta S, Cho J-S, Dur O et al (2013) Computer modeling for the prediction of thoracic aortic stent graft collapse. J Vasc Surg. Google Scholar
  47. Pasta S, Scardulla F, Rinaudo A et al (2016) An in vitro phantom study on the role of the bird-beak configuration in endograft infolding in the aortic arch. J Endovasc Ther 23:172–181. CrossRefGoogle Scholar
  48. Perrin D, Badel P, Orgéas L et al (2015a) Patient-specific numerical simulation of stent-graft deployment: validation on three clinical cases. J Biomech 48:1868–1875. CrossRefGoogle Scholar
  49. Perrin D, Demanget N, Badel P et al (2015b) Deployment of stent grafts in curved aneurysmal arteries: toward a predictive numerical tool. Int J Numer Method Biomed Eng 31:e02698. CrossRefGoogle Scholar
  50. Prasad A, To LK, Gorrepati ML et al (2011) Computational analysis of stresses acting on intermodular junctions in thoracic aortic endografts. J Endovasc Ther 18:559–568. CrossRefGoogle Scholar
  51. Reuben BC, Whitten MG, Sarfati M, Kraiss LW (2007) Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg 46:1222–1226. CrossRefGoogle Scholar
  52. Rinaudo A, Raffa GM, Scardulla F et al (2015) Biomechanical implications of excessive endograft protrusion into the aortic arch after thoracic endovascular repair. Comput Biol Med 66:235–241. CrossRefGoogle Scholar
  53. Roccabianca S, Figueroa CA, Tellides G, Humphrey JD (2014) Quantification of regional differences in aortic stiffness in the aging human. J Mech Behav Biomed Mater 29:618–634. CrossRefGoogle Scholar
  54. Romarowski RM, Faggiano E, Conti M et al (2018) A novel computational framework to predict patient-specific hemodynamics after TEVAR: integration of structural and fluid-dynamics analysis by image elaboration. Comput Fluids. zbMATHGoogle Scholar
  55. Saini A, Berry C, Greenwald S (1995) Effect of age and sex on residual stress in the aorta. J Vasc Res 32:398–405. CrossRefGoogle Scholar
  56. Sauaia A, Moore FA, Moore EE et al (1995) Epidemiology of trauma deaths: a reassessment. J Trauma 38:185–193CrossRefGoogle Scholar
  57. Schumacher H, Böckler D, von Tengg-Kobligk H, Allenberg J-R (2006) Acute traumatic aortic tear: open versus stent-graft repair. Semin Vasc Surg 19:48–59. CrossRefGoogle Scholar
  58. Sugawara J, Hayashi K, Yokoi T, Tanaka H (2008) Age-associated elongation of the ascending aorta in adults. JACC Cardiovasc Imaging 1:739–748. CrossRefGoogle Scholar
  59. Van Loon P, Klip W, Bradley E (1977) Length-force and volume-pressure relationships of arteries. Biorheology 14:181–201CrossRefGoogle Scholar
  60. Wolf YG, Tillich M, Lee Wa et al (2001) Impact of aortoiliac tortuosity on endovascular repair of abdominal aortic aneurysms: evaluation of 3D computer-based assessment. J Vasc Surg 34:594–599. CrossRefGoogle Scholar
  61. Xenos ES, Abedi NN, Davenport DL et al (2008) Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg 48:1343–1351. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of BiomechanicsUniversity of NebraskaOmahaUSA
  2. 2.Department of SurgeryUniversity of Nebraska Medical CenterOmahaUSA

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