Medical Engineering & Physics 23 (2001) 647655

www.elsevier.com/locate/medengphy

Fluidstructure interaction within realistic three-dimensional

models of the aneurysmatic aorta as a guidance to assess the risk
of rupture of the aneurysm
E.S. Di Martino a, G. Guadagni a, A. Fumero b, G. Ballerini c, R. Spirito b, P. Biglioli b,
A. Redaelli a,*
a
Department of Bioengineering, Politecnico of Milano, Milan, Italy
b
Vascular Unit, IRCCS Centro Cardiologico, Milan, Italy
c
Department of Radiology, IRCCS Centro Cardiologico, Milan, Italy

Received 20 June 2001; received in revised form 29 August 2001; accepted 13 September 2001

Abstract

Abdominal aortic aneurysm (AAA) disease is a degenerating process whose ultimate event is the rupture of the vessel wall.
Rupture occurs when the stresses acting on the wall rise above the strength of the AAA wall tissue. The complex mechanical
interaction between blood flow and wall dynamics in a three dimensional custom model of a patient AAA was studied by means
of computational coupled fluidstructure interaction analysis. Real 3D AAA geometry is obtained from CT scans image processing.
The results provide a quantitative local evaluation of the stresses due to local structural and fluid dynamic conditions. The method
accounts for the complex geometry of the aneurysm, the presence of a thrombus and the interaction between solid and fluid. A
proven clinical efficacy may promote the method as a tool to determine factual aneurysm risk of rupture and aid the surgeon to
refer elective surgery patients. 2002 Published by Elsevier Science Ltd on behalf of IPEM.

Keywords: Aortic aneurysm; Wall mechanics; Fluidstructure interaction

1. Introduction dence that also small aneurysms can rupture abruptly,

Abdominal aortic aneurysm (AAA) is a degenerative
disease which involves dilation and weakening of the
aorta. The prevalence of AAA is 8.8% in a population
above 65 years according to a recent study [1]. If left
untreated the aneurysm would grow steadily until rup-
ture. The decision between elective surgical repair of
AAA and conservative management, with periodic con-
trols, is a complex issue due to the lack of rupture risk
indices. The maximum transversal diameter of AAA
greater than a threshold value of 5 or 6 cm, is most com-
monly used in clinical practice to recommend surgical
intervention. This criterion has been supported by scien-
tific literature [24]. Nonetheless there is clinical evi-
* Corresponding author. Tel.: +39-02-23993361; fax: +39-02-
23993360.
E-mail address: redaelli@biomed.polimi.it (A. Redaelli).
with a peri-operative mortality exceeding 50% [511].
Accordingly, surgical aneurysm correction should be
guided not by transversal diameter measurements but by
more reliable parameters associated with the actual risk
of rupture of the specific vessel [1214]. From the mech-
anical point of view, AAA ruptures if the stresses acting
on the wall rise above the ultimate value for the AAA
wall tissue. Yet, no direct measurement is feasible of
stresses or strength in vivo. Stresses in AAA wall are
due to the concomitant influence of many factors, among
them the shape of the aneurysm formation, the character-
istics of the wall material, the shape and characteristics
of the intraluminal thrombus (ILT) when present, the
eccentricity of the patent lumen and the interaction
between the fluid and solid domains. Mathematical mod-
els can be used to simulate AAA mechanics. Many stud-
ies including some from the authors have addressed the
role played by geometry of the aneurysm and ILT. Some
studies show that the pressure inside the thrombus is not

1350-4533/02/$22.00 2002 Published by Elsevier Science Ltd on behalf of IPEM.

PII: S 1 3 5 0 - 4 5 3 3 ( 0 1 ) 0 0 0 9 3 - 5
648 E.S. Di Martino et al. / Medical Engineering & Physics 23 (2001) 647655
reduced with respect to the arterial blood pressure, some
state a possible protective role [1517]. Stresses in the
aortic wall have been shown, in a previous study by the
authors, to be strictly dependent upon the thickness, and
the characteristics of ILT, which appears to act as a
cushion against the overpressure on the dilated and
degenerated wall [18]. Asymmetry and geometry irregu-
larities have been shown to play a determinant role
[1922]. This has given rise to custom-built models of
AAA obtained from diagnostic images that allow the
simulation of the single patient status [23]. Indeed, cus-
tom models are likely to become a powerful tool for
surgical decision making. Purpose of this study was to
simulate the complex mechanical interaction between
blood flow and wall dynamics in a custom model of
AAA by means computational coupled fluidstructure
interaction analyses. Real 3D AAA geometry is obtained
from CT scans image processing. The case studied is a
patient operated at Centro Cardiologico Fondazione
Monzino of Milan, Italy. Time dependent pulsatile
boundary conditions have been used in order to simulate
the behaviour of the aneurysm in a typical cardiac cycle
[24]. The method provides velocity and pressure quanti-
fication throughout the volume studied, as well as a
quantification of the stresses acting in the AAA wall due
to blood flow and arterial wall mechanics. These stresses
value can be compared with mean AAA strength and
provide a risk predictor for AAA rupture.
2. Material and methods
2.1. Geometric reconstruction from CT scan images
Diagnostic images provide 2D information about the
shape of each slice of the vessel studied. A procedure
has been developed to construct the exterior and interior
surfaces of the abdominal aorta from a set of CT images
(one slice every 5 mm in the axial direction) [25]. CT
scans are obtained with a Toshiba Xpress helical CT
scanner. Many software packages are available that pro-
vide image processing functions. To meet our require-
ments, the MegaWave2 (MW2) software (CEREMADE,
University of Paris IX-Dauphine, 75775 Paris, France)
has been chosen due to powerful built-in image pro-
cessing library and open programming environment,
which allows the creation of C-language self-developed
routines. The steps of the procedure include:
1. conversion of CT data into a file format compatible
to processing software. This procedure rewrites the
header file of each image, to make it readable in the
MW2 environment,
2. pre processing aimed to improve the quality of the
image volume. 3D convolution with a 333 gaussian
kernel which reduces the background noise present in
the images has been performed,
3. segmentation of the 2D images based on a region
growing method. A first regional segmentation with
a greater number of partitioning regions than neces-
sary is performed on each single slice. A threshold
binarisation process is then applied in order to remove
sub-regions unrelated to the vessel lumen. After
binarisation, the region growing procedure is applied
again, setting the number of regions for the algorithm
equal to two. Once the region of interest is segmented
a binarization is performed in order to obtain the con-
tour of interest. The procedure has been applied twice
to each slice, the first time lumen is extracted auto-
matically by the procedure, the second time the exter-
nal contour of AAA is extracted: due to adhesions
and poor contrast manual editing of the image was
necessary at this level. The external contour of AAA
was then obtained binarizing the image after man-
ual editing,
4. smoothing of the contours. Automatic moving aver-
age between the spatial co-ordinates. This step returns
a set of formatted ASCII files containing the spatial
co-ordinates, x, y and z of the nodes which define the
boundary of each slice. This is done twice, one for
the lumen and one for the external wall,
5. creation of the 3D surfaces representing the blood
lumen and the wall contours from the point cloud
using the module Cloud of the commercial CAD
package Catia (Catia, Dassault Systemes, Paris).
In spite of intravenous contrast medium being adminis-
tered, a clear distinction between thrombus and AAA
wall was not achieved. Therefore, the aortic wall surface
has been created considering a constant thickness of the
wall of 2 mm. The different solid and fluid domains
aortic wall, thrombus formation and bloodwere then
created on the basis of those surfaces. In Fig. 1 a CT
image processed and the three-dimensional model of the
aneurysm are depicted. This procedure has been applied
to study a patient subjected to routine pre-operative CT
exams at Centro Cardiologico Fondazione Monzino,
Milano.
2.2. Fluidstructure interaction computational
analyses
In Fig. 2 the FEM models of the aneurysm, interior
and exterior, are depicted, and a blow up shows one
brick element. The simulation of the complete cardiac
cycle is performed by means of a fluidstructure interac-
tion approach. This technique allows to study the aneur-
ysmatic fluid-mechanics by accounting both for the
instantaneous fluid forces acting on the wall and the
effects of the wall motion on the fluid dynamic field.
Operatively a ALE (Arbitrary Lagrangian Eulerian)
 E.S. Di Martino et al. / Medical Engineering & Physics 23 (2001) 647655
Fig. 1. Tomographic image and three dimensional geometric model of an aneurysm.
Fig. 2. Discretised FEM model of the aneurysm. In light grey is the
exterior wall, in medium grey the inner thrombus, in dark grey the
fluid domain. The inset shows an eight-node isoparametric brick
element and the velocity vectors that are calculated per each node.
algorithm is used that seeks, at each increment of the
step, the convergence of the three blocks of equations,
fluid (CFD), solid (CSD) and mesh movements (CMD)
which must then converge altogether before a new step
is initiated [26].
649
The equations governing the fluid (CFD) are:
u
r +rui,j (uj uj )=sij,j +rfi
i
in F(t) (1)
r
+(ruj ),j =0
t
where ui is the velocity, r is the fluid density, sij is the
stress, fi is the body force at time t per unit mass, u is
the mesh velocity at time t and F(t) is the moving spa-
tial domain upon which the fluid is described. For a
nearly incompressible fluid the first term of the second
equation is equal to zero.
The equations governing the structural domain (CSD)
are the momentum equations, the equilibrium conditions
and the constitutive equations, respectively:
raisij,j rfi in S(t) (2)
sij nj ti on S(t) (3)
sij Dijklekl in S(t) (4)
where ai is the acceleration of a material point, S(t) is
the structural domain at time t, nj is the outward pointing
normal on S(t), ti is the surface traction vector at time
t, S(t) is the boundary of the structural domain, Dijkl is
the lagrangian elasticity tensor, and ekl is the infinitesi-
mal strain tensor.
The mesh is deformed (CMD) under the assumption
that it behaves like an elastic medium described by the
same equations used for the structural domain.
The code Fidap (Fluent Inc., Lebanon, NH) has been
used to carry out the simulation. The discretisation is
made of 1600 eight-node brick elements for the solid
domain and 11000 eight-node brick elements for the
fluid domain.
The boundary conditions are time-dependent. The
650 E.S. Di Martino et al. / Medical Engineering & Physics 23 (2001) 647655
velocity inlet boundary conditions are taken from Colour
Doppler measurements of the aortic blood average velo-
city (Fig. 3). Since in pulsatile condition the velocity
profile changes during the cardiac cycle, a cylindrical
inlet channel (5 diameters long) has been modelled in
the upper part of the aneurysm; the fully developed pro-
file has been obtained at the aneurysm inlet by imposing
a flat velocity profile at the inlet channel. A time-depen-
dent isobaric pressure is imposed at the outlet. The press-
ure is relative to a basal pressure of 80 mmHg (Fig. 3).
The upper surface of the inlet channel is fixed. The axial
displacements of the outlet surface is not allowed while
the radial enlargement is free.
At the beginning of the simulation the fluid is quiesc-
ent and three cardiac cycles have been simulated in order
to achieve a solution independent from the initial con-
ditions.
The fluid is Newtonian with a density of 1060 kg/m3
and a viscosity of 0.0027 Pa s. Blood is essentially a
suspension of erythrocytes in plasma and shows anomal-
ous viscous properties at low velocities. However, the
Newtonian assumption has been considered acceptable
since minor differences in the basic flow characteristics
are introduced through the non-Newtonian hypothesis
[27]. Moreover, especially when the velocities are low,
the wall shear stresses are several orders of magnitude
lower than the stress due to the pressure acting on the
wall; consequently, the wall overall stress is minimally
influenced by the non-Newtonian behaviour.
As for the mechanical static and dynamic character-
istics of the aortic wall and of the thrombus, experi-
mental tests have been performed on specimens obtained
during surgical aneurysm treatment, using a MTS Syner-
gie 200H System, with a loading cell of 1 kN (Fig. 4).
Uniaxial tests in both circumferential and longitudinal
Fig. 3. Velocity profile imposed at the inlet channel and pressure
profile imposed at the outlet.
direction have been performed on aneurysmatic wall
specimens and healthy specimens (from aortic homo-
graft samples) and show that the aneurysmatic pathology
implies a more rigid behaviour and a diminished value
for the stress limit value. Aneurysmatic specimens show
a similar behaviour in the two directions tested, which
is not met for healthy specimens. In Fig. 4 an example
of a stressstrain characteristic from an aneurysmatic
specimen obtained during surgery is depicted; a circum-
ferential stressstrain curve obtained from a healthy
specimen is also addressed for qualitative comparison
[28].
The wall material implemented in the FEM model rep-
resents an aortic wall tissue of medium characteristics
as regards our tests. Due to the actual limitations of the
code Fidap, linear elastic homogeneous approximation
of the non-linear behaviour of the wall was necessary to
comply with the code requirements. Walls Young
modulus was then set to 2.7 MPa, the value being a lin-
earisation about the working point of the se curve.
Poisson coefficient is 0.45 (nearly incompressible
material). Recently, Raghavan and colleagues have
shown that the wall behaviour may be described success-
fully by means of a non-linear isotropic hyperelastic
material model defined through mechanical uniaxial tests
[29]. We are presently working on the implementation of
non-linear viscoelastic material models within the code
Fidap, by means of user-subroutines.
A previous study by the authors has addressed the
mechanical characteristics of the thrombus; the results
obtained from mechanical tests on thrombus specimen
(organised thrombus specimens were selected) indicated
a linear elastic isotropic behaviour with an elastic modu-
lus ranging from 0.03 to 0.2 MPa [18]. In the simulations
thrombus has been therefore modelled as a linear elastic
homogeneous material with Young modulus equal to
0.11 (mean value from the experimental tests) and Pois-
son coefficient 0.45 (nearly incompressible material).
3. Results
Motion of aneurysmatic wall is not homogeneous due
to the asymmetric shape of the aneurysm, the complex
fluid dynamic pattern, and the heterogeneity of the wall
thickness. As a consequence the stress pattern is hetero-
geneous as shown in Fig. 5 for the systolic peak. Being
the pressure relative to a basal pressure of 80 mmHg,
the calculated stresses are stress increments s which
add to the basal 80 mmHg stress. Since the stress a
second order tensor with nine components, the energetic
formulation by von Mises is adopted to present stress
results. Equivalentvon Misesstress characterises the
distortional energy (s2/E) within a component and pro-
vides stress information in terms of equivalent positive
defined scalar stress levels. In Fig. 6 the velocity con-
 E.S. Di Martino et al. / Medical Engineering & Physics 23 (2001) 647655
Fig. 4. Aneurysmatic specimen mounted in the tensile test machine (left) and stressdeformation curves obtained (right). The dashed line represents
the stressdeformation curve for a healthy aortic wall sample (with SD).
Fig. 5. Stress contours (von MisesMPa) at systolic peak depicted
on two views of the aneurysm model.
tour, the pressure contour and the displacements calcu-
lated in a longitudinal cross-section of the aneurysm are
depicted at the three instants of the cardiac cycle shown
in Fig. 3. The velocity is close to zero at the inner bound-
651
ary (depicted in blue) and reaches its maximum values
towards the centre of the aneurysm (in red). At time T2,
corresponding to the systolic peak, the area of maximum
velocity is larger; a flow deceleration is always discern-
ible (at each time T1, T2, T3) at the site of larger aneur-
ysm section, this implies the pressure being higher at
this site. This may be the source of aneurysm further
enlargement, together with wall weakening. The third
column of Fig. 6 shows two configurations, where
thicker line represents the deformed geometry and thin-
ner line the original one. Sites of maximum displace-
ments and strain are the regions of thinner wall, and the
regions of curvature change.
Fig. 7 shows the von Mises stress contours (s) for
three different sections of the aneurysm. The locations
of the three section planes are shown in the same picture.
As clearly shown by the different sections of Fig. 7, the
load is almost completely sustained by the aortic wall,
the thrombus acting as a cushion for pressure. Sites of
maximum stresses depend on the thickness of the throm-
bus layer as well as on the curvature and diameter size
of the portion of vessel analysed. In particular, the
thicker is the thrombus layer the less is the magnitude
of the equivalent von Mises stress.
4. Discussion
The prediction of the course of an aneurysm is a cru-
cial item, which has been recently addressed by several
authors. The majority reports clinical studies focused on
statistically appreciable aneurysm risk factors like
growth rate or transversal maximum diameter, and their
correlation with operative management and planning
[2,3,13,14,30,31].
The most broadly established parameter looked at by
652 E.S. Di Martino et al. / Medical Engineering & Physics 23 (2001) 647655

Fig. 6. Velocity, pressure and displacements are depicted in a section of the aneurysm calculated at characteristic instants of the cardiac cycle
(T1, T2, T3) shown in Fig. 3.

surgeons to determine the risk of rupture of an aneurysm
is its maximum transversal diameter. Its efficacy may be
inferred with reference to Laplace law which asserts that
the stress in a cylinder depends on the inner pressure,
the radius and the thickness of the wall, namely
sJJ=(Pr)/s where sJJ represents the circumferential
stress, P is the blood pressure, r is half the aneurysm
diameter and s is the thickness of the vessel wall.
Laplace law, when the pressure and the thickness are
constant, states that the larger the aneurysm diameter is,
the larger the wall stresses and thereby the rupture risk
[32]. Nonetheless, Laplace law is based on strict hypoth-
eses which are unsatisfied when applied to aneurysms
biomechanics: simple geometry, small wall thickness to
 E.S. Di Martino et al. / Medical Engineering & Physics 23 (2001) 647655
Fig. 7. von Mises (MPa) stresses plots on three different sections of the aneurysm model.
diameter ratio (i.e. thickness is less than one-tenth of
the diameter), linear elastic homogeneous material, static
pressure load. The stress distribution depicted in Fig. 7
is heterogeneous depending on the axial cutting plane
and would be unpredictable by using Laplace law.
Recently, many authors have pointed out the need for
more realistic predictive models [11,12,33]. Clinical
indexes aimed at the evaluation of AAA risk of rupture
have been proposed inferred from echographic measure-
ments of the systolic to diastolic aortic diameter change:
the pressure strain elastic modulus (Ep), calculated as
the ratio between the systolic to diastolic pressure differ-
ence and the circumpherential strain and the stiffness b,
where the logarithm of the relative pressure is used
instead of the pressure difference [34,35]. However,
weak or even no correlations have been found between
growth rate and Ep or b [35,36].
The reason may be twofold: firstly, despite Ep and b
may be correlated to the wall material properties, they
are not, from a mechanical standpoint, actual measures
of compliance and stiffness. Secondly they are global
indexes and do not account for the local behaviour of
the wall.
Our approach is aimed at taking into account, all
together, the factors pertinent to aneurysm wall stresses,
from the mechanical standpoint: real 3D vessel mor-
phology, fluidstructure interaction and aneurysm wall
tissue mechanical constitutive parameters. The result is
653
a locally quantifiable depiction of the stresses in the ane-
urysmatic wall.
According to previous works, the asymmetric shape
of the bulge and the changes of curvature, observed
through 3D clinical imaging, play a crucial role in aneur-
ysm mechanics. Elger and colleagues studied simple axi-
symmetric hypothetical AAA and verified that maximum
hoop stresses tend to be larger, at constant maximum
diameter, for smaller curvature aneurysm shape [22].
Vorp and colleagues showed that the peak stress
increases with increasing maximum diameter or increas-
ing asymmetry [19]. Recently, Sacks and co-workers
have proposed an imaging based method for the evalu-
ation of the local principal curvatures (K1, K2) of the
external vessel wall [37]. Their results show that AAA
surface geometry is highly complex suggesting an equ-
ally complex wall stress distribution.
Our approach takes into account the vessel internal
morphology, blood flow and wall thickness. This has a
twofold implication:
(i) It allows the estimation of the effect of thrombus
layer on wall stresses. Mower et al. [29] have shown
that the thrombus layer thickness plays a protective
role with respect to AAA wall: the thicker is the
thrombus, the less is the stress concentration intensity.
The location of the lumen, i.e. the lumen eccentricity
with respect to the outer diameter of the aneurysm
654 E.S. Di Martino et al. / Medical Engineering & Physics 23 (2001) 647655
affects as well the wall stress as shown in a previous
study by the authors [18].
(ii) It comprises the simulation of aneurysm fluid
dynamics and its effect on aneurysm wall mechanics.
Several studies have brought up the importance of
aneurysm fluid dynamics, which may influence rup-
ture onset. Bluestein and colleagues have reported
that vortex formation inside the aneurysm cavity cre-
ates the conditions that promote thrombus formation
and the viability of rupture [38]. Taylor and Yamagu-
chi have shown that the vortexes at the exit cause
high-pressure regions potentially critical for rupture
[39]. Also the presence of turbulent flow may signifi-
cantly affect risk of rupture due both to high shear
stresses and reducing the pressure at the aneurysm
bulge. The results of the fluidstructure interaction
simulation demonstrate the link between the fluid
dynamic field and the wall stresses that in the cited
works could only be inferred on the basis of mechan-
ical remarks.
Despite the advanced features of the presented approach,
the uncertainties about the aneurysmatic wall mechanical
behaviour limit its application in clinics. The elastic
modulus, the rupture stress (s*) and the basal stresses
are data related to the single patient status and strongly
influence the rupture prediction. The mechanical behav-
iour of an aneurysmatic aortic sample differs consider-
ably from a healthy one depending on changes in the
composition and structure in the matrix components
[29,34,4042]. As shown in Fig. 4, the elastin-dependent
low modulus elastic behaviour shown by a healthy speci-
men up to deformation near to fifty% completely disap-
pears in the aneurysmatic specimens due to elastin
degeneration. Also, the rupture stress value typically
decreases dramatically. Moreover hypertension enhances
the risk of aneurysm rupture since it increases the basal
stress values.
Currently the model is used under standard assump-
tions of a basal pressure of 80 mmHg, and an elastic
modulus for the wall of 2.7 MPa and of 0.11 MPa for
the thrombus. Consequently, the results do not provide
the actual wall stresses of the patient under examination.
They provide information on the stress pattern and could
be used to compare different aneurysm geometries.
Prospectively, a further step will include the segmen-
tal analysis of the wall motion through high-resolution
non-invasive imaging techniques in order to assign local
wall characteristics. This approach is expected to provide
details about wall motion anomalies due to the thinning,
stiffening or weakening of the wall. In the authors opi-
nion, the implementation of this information in the
presented model is fundamental for the comprehension
of aneurysm rupture.
Acknowledgements
The authors would like to acknowledge the Italian
Ministry for Research and University (MURST) for par-
tial funding. We also acknowledge Dr. Eng. Giovanna
Rizzo of the Department of Nuclear Medicine of San
Raffaele Hospital (Milan) for the image tool develop-
ment and Antonio Succu of the department of Radiology
of Centro Cardiologico (Milan) for his useful help on
CT scanner equipment.
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