Impact of the stent footprint on endothelial wall shear stress in patient-specific coronary arteries: A computational analysis from the SHEAR-STENT trial

Background and Objective:

Wall shear stress (WSS) has been known to play a critical role in the development of several complications following coronary artery stenting, including in-stent restenosis and thrombosis. Computational fluid dynamics is often used to quantify the post-stenting WSS, which may potentially be used as a predictive metric. However, large-scale studies for WSS-based risk stratification often neglect the footprint of the stent due to reconstruction challenges. The primary objective of this study is to statistically evaluate the impact of the stent footprints (Xience and Resolute stents) on the computed endothelial WSS and quantitatively identify the relationship between these local hemodynamic alterations and the global properties of the vessel, such as curvature, on WSS. The ultimate goal is to evaluate whether and when it is worth including the footprint of the stent in an in-silico study to compute the WSS reliably.

Methods:

A previously developed semi-automated reconstruction approach for patient-specific coronaries was employed as a part of the SHEAR-STENT trial. A subset of patients was analyzed ($N=30$), and CFD simulations were performed with and without the stent to evaluate the impact of the stent footprint on WSS. Due to the computationally expensive nature of transient analyses, a sub-cohort of ten patients were used to assess the reliability of WSS obtained from steady computations as a surrogate for the time-averaged results. Global and local vessel curvature data were extracted for all cases and evaluated against stent-induced alterations in the WSS. The differences between the Xience and Resolute stent platforms were also examined to quantify each stent’s unique WSS footprint.

Results:

Results from the surrogate analysis indicate that steady WSS serves as an excellent approximation of the time-averaged computations. The presence of either stent footprint causes a statistically significant decrease in the space-averaged WSS, and a significant increase in the endothelial regions exposed to very low WSS as well ($<0.5$ Pa). Negative correlations were observed between vessel curvature and WSS differences, indicating that macroscopic vessel characteristics play a more prominent role in determining endothelial WSS at higher curvature values. In our pool of cases, comparison of Xience and Resolute stents revealed that the Resolute platform seems to lead to lower space-averaged WSS and an increase in areas of very low WSS.

Conclusion:

These results outline (1) the necessity of including the stent footprint for accurate in-silico WSS analysis; (2) the global features of stented arteries serving as the dominant determinant of WSS past a certain curvature threshold; and (3) the Xience stent resulting in a milder presence of hemodynamically unfavorable WSS regions compared to the Resolute stent.