Effect of lower limb amputation level on aortic hemodynamics: a numerical study_Journal of Biomedical Engineering

Authors：

WEI Junru ^1,2 , LI Zhongyou ^1,2 , DIAO Junjie ^1,2 , LI Xiao ^1,2 , MIN Lei ^1,2 ,  JIANG Wentao ^1,2 , YAN Fei ³

1. Biomechanical Engineering Laboratory, Sichuan University, Chengdu 610065, P. R. China;
2. Failure Mechanics and Engineering Disaster Prevention and Mitigation Key Laboratory of Sichuan Province, Chengdu 610065, P. R. China;
3. Chongqing University Three Gorges Hospital, Chongqing 404000, P. R. China;

Corresponding author：

JIANG Wentao, Email: scubme_jwt@outlook.com

Keywords：

Cardiovascular diseases; Lower limb amputation; Hemodynamics; Windkessel model

DOI：

10.7507/1001-5515.202108031

Video：

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It has been found that the incidence of cardiovascular disease in patients with lower limb amputation is significantly higher than that in normal individuals, but the relationship between lower limb amputation and the episodes of cardiovascular disease has not been studied from the perspective of hemodynamics. In this paper, numerical simulation was used to study the effects of amputation on aortic hemodynamics by changing peripheral impedance and capacitance. The final results showed that after amputation, the aortic blood pressure increased, the time averaged wall shear stress of the infrarenal abdominal aorta decreased and the oscillatory shear index of the left and right sides was asymmetrically distributed, while the time averaged wall shear stress of the iliac artery decreased and the oscillatory shear index increased. The changes above were more significant with the increase of amputation level, which will result in a higher incidence of atherosclerosis and abdominal aortic aneurysm. These findings preliminarily revealed the influence of lower limb amputation on the occurrence of cardiovascular diseases, and provided theoretical guidance for the design of rehabilitation training and the optimization of cardiovascular diseases treatment.

Citation： WEI Junru, LI Zhongyou, DIAO Junjie, LI Xiao, MIN Lei, JIANG Wentao, YAN Fei. Effect of lower limb amputation level on aortic hemodynamics: a numerical study. Journal of Biomedical Engineering, 2022, 39(1): 67-74. doi: 10.7507/1001-5515.202108031 Copy

1.	Modan M, Peles E, Halkin H, et al. Increased cardiovascular disease mortality rates in traumatic lower limb amputees. Am J Cardiol, 1998, 82(10): 1242-1247.
2.	Hrubec Z, Ryder R A. Traumatic limb amputations and subsequent mortality from cardiovascular disease and other causes. J Chronic Dis, 1980, 33(4): 239-250.
3.	Yekutiel M, Brooks M E, Ohry A, et al. The prevalence of hypertension, ischaemic heart disease and diabetes in traumatic spinal cord injured patients and amputees. Paraplegia, 1989, 27(1): 58-62.
4.	Vollmar J F, Paes E, Pauschinger P, et al. Aortic aneurysms as late sequelae of above-knee amputation. Lancet, 1989, 334(8667): 834-835.
5.	Frugoli B A, Guion W K, Joyner B A, et al. Cardiovascular disease risk factors in an amputee population. Medicine and Science in Sports and Exercise, 2000, 33(5): S266.
6.	Peles E, Akselrod S, Goldstein D S, et al. Insulin resistance and autonomic function in traumatic lower limb amputees. Clin Auton Res, 1995, 5(5): 279-288.
7.	Bhatnagar V, Richard E, Melcer T, et al. Retrospective study of cardiovascular disease risk factors among a cohort of combat veterans with lower limb amputation. Vasc Health Risk Manag, 2019, 15: 409-418.
8.	Pohjolainen T, Alaranta H. Ten-year survival of finnish lower limb amputees. Prosthet Orthot Int, 1998, 22(1): 10-16.
9.	Jones W S, Patel M R, Dai D, et al. High mortality risks after major lower extremity amputation in medicare patients with peripheral artery disease. Am Heart J, 2013, 165(5): 809-815, e1.
10.	Nerem R M, Harrison D G, Taylor W R, et al. Hemodynamics and vascular endothelial biology. J Cardiovasc Pharmacol, 1993, 21: S6-10.
11.	Samady H, Eshtehardi P, Mcdaniel M C, et al. Coronary artery wall shear stress is associated with progression and transformation of atherosclerotic plaque and arterial remodeling in patients with coronary artery disease. Circulation, 2011, 124(7): 779-788.
12.	Xiao N, Alastruey J, Figueroa C A. A systematic comparison between 1-d and 3-d hemodynamics in compliant arterial models: a comparison of 1-d and 3-d hemodynamics in compliant arterial models. International Journal for Numerical Methods in Biomedical Engineering, 2014, 30(2): 204-231.
13.	Betts J G, Young K A, Wise J A, et al. Blood flow, blood pressure, and resistance//Anatomy and Physiology. Houston, Texas: OpenStax, 2013, [2021-07-11]. https://openstax.org/books/anatomy-and-physiology/pages/20-2-blood-flow-blood-pressure-and-resistance.
14.	Alastruey J, Parker K H, Peiro J, et al. Lumped parameter outflow models for 1-d blood flow simulations: effect on pulse waves and parameter estimation. Commun Comput Phys, 2008, 4(2): 317-336.
15.	Xiao N, Humphrey J D, Figueroa C A. Multi-scale computational model of three-dimensional hemodynamics within a deformable full-body arterial network. J Comput Phys, 2013, 244: 22-40.
16.	Williams L R, Leggett R W. Reference values for resting blood flow to organs of man. Clin Phys Physiol Meas, 1989, 10(3): 187-217.
17.	Olufsen M S, Peskin C S, Kim W Y, et al. Numerical simulation and experimental validation of blood flow in arteries with structured-tree outflow conditions. Ann Biomed Eng, 2000, 28(11): 1281-1299.
18.	Stergiopulos N, Young D F, Rogge T R. Computer simulation of arterial flow with applications to arterial and aortic stenoses. J Biomech, 1992, 25(12): 1477-1488.
19.	Paula-Ribeiro M, Garcia M M, Martinez D G, et al. Increased peripheral vascular resistance in male patients with traumatic lower limb amputation: one piece of the cardiovascular risk puzzle. Blood Press Monit, 2015, 20(6): 341-345.
20.	Röcker L, Taenzer M, Drygas W K, et al. Effect of prolonged physical exercise on the fibrinolytic system. Eur J Appl Physiol Occup Physiol, 1990, 60(6): 478-481.
21.	汪炎秋. 左冠状动脉分叉角对血流动力学特性的影响研究. 济南:山东大学, 2020.
22.	Taylor C A, Hughes T J, Zarins C K. Finite element modeling of three-dimensional pulsatile flow in the abdominal aorta: relevance to atherosclerosis. Ann Biomed Eng, 1998, 26(6): 975-987.
23.	Nyboer J, Murray P, Sedensky J A. Blood-flow indices in amputee and control limbs by mutual electrical impedance plethysmography. Am Heart J, 1974, 87(6): 704-710.
24.	Huonker M, Schmid A, Schmidt-Trucksass A, et al. Size and blood flow of central and peripheral arteries in highly trained able-bodied and disabled athletes. J Appl Physiol, 2003, 95(2): 685-691.
25.	刘大为. 临床血流动力学. 北京: 人民卫生出版社, 2013:17-53, 130-140.
26.	Laurent S, Boutouyrie P. The structural factor of hypertension: large and small artery alterations. Circ Res, 2015, 116(6): 1007-1021.
27.	Naschitz J E, Lenger R. Why traumatic leg amputees are at increased risk for cardiovascular diseases. Qjm-Mon J Assoc Phys, 2008, 101(4): 251-259.
28.	Hoshina K, Sho E, Sho M, et al. Wall shear stress and strain modulate experimental aneurysm cellularity. J Vasc Surg, 2003, 37(5): 1067-1074.
29.	Solonen K A, Rinne H J, Viikeri M, et al. Late sequelae of amputation the health of finnish amputated war veterans. Ann Chir Gynaecol, 1965: 54.
30.	姚泰. 人体生理学(下册) , 译. 第3版. 北京: 人民卫生出版社, 2001: 1273-1290.
31.	Davies P F. Hemodynamic shear stress and the endothelium in cardiovascular pathophysiology. Nat Clin Pract Cardiovasc Med, 2009, 6(1): 16-26.
32.	Traub O, Berk B C. Laminar shear stress: mechanisms by which endothelial cells transduce an atheroprotective force. Arterioscler Thromb Vasc Biol, 1998, 18(5): 677-685.
33.	Chatzizisis Y S, Coskun A U, Jonas M, et al. Role of endothelial shear stress in the natural history of coronary atherosclerosis and vascular remodeling. J Am Coll Cardiol, 2007, 49(25): 2379-2393.
34.	Chiu J J, Chien S. Effects of disturbed flow on vascular endothelium: pathophysiological basis and clinical perspectives. Physiol Rev, 2011, 91(1): 327-387.
35.	Guo Ziyi, Yan Zhiqiang, Bai Ling, et al. Flow shear stress affects macromolecular accumulation through modulation of internal elastic lamina fenestrae. Clin Biomech, 2008, 23: S104-S111.
36.	Lehoux S, Castier Y, Tedgui A. Molecular mechanisms of the vascular responses to hemodynamic forces. J Intern Med, 2006, 259(4): 381-392.
37.	Berk B C, Korshunov V A. Genetic determinants of vascular remodeling. Can J Cardiol, 2006, 22: 6B-11B.
38.	Golledge J. Abdominal aortic aneurysm: update on pathogenesis and medical treatments. Nat Rev Cardiol, 2019, 16(4): 225-242.
39.	Dua M M, Dalman R L. Hemodynamic influences on abdominal aortic aneurysm disease: application of biomechanics to aneurysm pathophysiology. Vascul Pharmacol, 2010, 53(1/2): 11-21.
40.	Boussel L, Rayz V, Mcculloch C, et al. Aneurysm growth occurs at region of low wall shear stress: patient-specific correlation of hemodynamics and growth in a longitudinal study. Stroke, 2008, 39(11): 2997-3002.
41.	姜宗来, 齐颖新. 血管力学生物学. 上海: 上海交通大学出版社, 2017: 128.
42.	Doyle B J, Callanan A, Burke P E, et al. Vessel asymmetry as an additional diagnostic tool in the assessment of abdominal aortic aneurysms. J Vasc Surg, 2009, 49(2): 443-454.
43.	Drzisga D, Köppl T, Pohl U, et al. Numerical modeling of compensation mechanisms for peripheral arterial stenoses. Comput Biol Med, 2016, 70: 190-201.
44.	Heil M, Schaper W. Influence of mechanical, cellular, and molecular factors on collateral artery growth. Circ Res, 2004, 95(5): 449-458.

1. Modan M, Peles E, Halkin H, et al. Increased cardiovascular disease mortality rates in traumatic lower limb amputees. Am J Cardiol, 1998, 82(10): 1242-1247.
2. Hrubec Z, Ryder R A. Traumatic limb amputations and subsequent mortality from cardiovascular disease and other causes. J Chronic Dis, 1980, 33(4): 239-250.
3. Yekutiel M, Brooks M E, Ohry A, et al. The prevalence of hypertension, ischaemic heart disease and diabetes in traumatic spinal cord injured patients and amputees. Paraplegia, 1989, 27(1): 58-62.
4. Vollmar J F, Paes E, Pauschinger P, et al. Aortic aneurysms as late sequelae of above-knee amputation. Lancet, 1989, 334(8667): 834-835.
5. Frugoli B A, Guion W K, Joyner B A, et al. Cardiovascular disease risk factors in an amputee population. Medicine and Science in Sports and Exercise, 2000, 33(5): S266.
6. Peles E, Akselrod S, Goldstein D S, et al. Insulin resistance and autonomic function in traumatic lower limb amputees. Clin Auton Res, 1995, 5(5): 279-288.
7. Bhatnagar V, Richard E, Melcer T, et al. Retrospective study of cardiovascular disease risk factors among a cohort of combat veterans with lower limb amputation. Vasc Health Risk Manag, 2019, 15: 409-418.
8. Pohjolainen T, Alaranta H. Ten-year survival of finnish lower limb amputees. Prosthet Orthot Int, 1998, 22(1): 10-16.
9. Jones W S, Patel M R, Dai D, et al. High mortality risks after major lower extremity amputation in medicare patients with peripheral artery disease. Am Heart J, 2013, 165(5): 809-815, e1.
10. Nerem R M, Harrison D G, Taylor W R, et al. Hemodynamics and vascular endothelial biology. J Cardiovasc Pharmacol, 1993, 21: S6-10.
11. Samady H, Eshtehardi P, Mcdaniel M C, et al. Coronary artery wall shear stress is associated with progression and transformation of atherosclerotic plaque and arterial remodeling in patients with coronary artery disease. Circulation, 2011, 124(7): 779-788.
12. Xiao N, Alastruey J, Figueroa C A. A systematic comparison between 1-d and 3-d hemodynamics in compliant arterial models: a comparison of 1-d and 3-d hemodynamics in compliant arterial models. International Journal for Numerical Methods in Biomedical Engineering, 2014, 30(2): 204-231.
13. Betts J G, Young K A, Wise J A, et al. Blood flow, blood pressure, and resistance//Anatomy and Physiology. Houston, Texas: OpenStax, 2013, [2021-07-11]. https://openstax.org/books/anatomy-and-physiology/pages/20-2-blood-flow-blood-pressure-and-resistance.
14. Alastruey J, Parker K H, Peiro J, et al. Lumped parameter outflow models for 1-d blood flow simulations: effect on pulse waves and parameter estimation. Commun Comput Phys, 2008, 4(2): 317-336.
15. Xiao N, Humphrey J D, Figueroa C A. Multi-scale computational model of three-dimensional hemodynamics within a deformable full-body arterial network. J Comput Phys, 2013, 244: 22-40.
16. Williams L R, Leggett R W. Reference values for resting blood flow to organs of man. Clin Phys Physiol Meas, 1989, 10(3): 187-217.
17. Olufsen M S, Peskin C S, Kim W Y, et al. Numerical simulation and experimental validation of blood flow in arteries with structured-tree outflow conditions. Ann Biomed Eng, 2000, 28(11): 1281-1299.
18. Stergiopulos N, Young D F, Rogge T R. Computer simulation of arterial flow with applications to arterial and aortic stenoses. J Biomech, 1992, 25(12): 1477-1488.
19. Paula-Ribeiro M, Garcia M M, Martinez D G, et al. Increased peripheral vascular resistance in male patients with traumatic lower limb amputation: one piece of the cardiovascular risk puzzle. Blood Press Monit, 2015, 20(6): 341-345.
20. Röcker L, Taenzer M, Drygas W K, et al. Effect of prolonged physical exercise on the fibrinolytic system. Eur J Appl Physiol Occup Physiol, 1990, 60(6): 478-481.
21. 汪炎秋. 左冠状动脉分叉角对血流动力学特性的影响研究. 济南:山东大学, 2020.
22. Taylor C A, Hughes T J, Zarins C K. Finite element modeling of three-dimensional pulsatile flow in the abdominal aorta: relevance to atherosclerosis. Ann Biomed Eng, 1998, 26(6): 975-987.
23. Nyboer J, Murray P, Sedensky J A. Blood-flow indices in amputee and control limbs by mutual electrical impedance plethysmography. Am Heart J, 1974, 87(6): 704-710.
24. Huonker M, Schmid A, Schmidt-Trucksass A, et al. Size and blood flow of central and peripheral arteries in highly trained able-bodied and disabled athletes. J Appl Physiol, 2003, 95(2): 685-691.
25. 刘大为. 临床血流动力学. 北京: 人民卫生出版社, 2013:17-53, 130-140.
26. Laurent S, Boutouyrie P. The structural factor of hypertension: large and small artery alterations. Circ Res, 2015, 116(6): 1007-1021.
27. Naschitz J E, Lenger R. Why traumatic leg amputees are at increased risk for cardiovascular diseases. Qjm-Mon J Assoc Phys, 2008, 101(4): 251-259.
28. Hoshina K, Sho E, Sho M, et al. Wall shear stress and strain modulate experimental aneurysm cellularity. J Vasc Surg, 2003, 37(5): 1067-1074.
29. Solonen K A, Rinne H J, Viikeri M, et al. Late sequelae of amputation the health of finnish amputated war veterans. Ann Chir Gynaecol, 1965: 54.
30. 姚泰. 人体生理学(下册) , 译. 第3版. 北京: 人民卫生出版社, 2001: 1273-1290.
31. Davies P F. Hemodynamic shear stress and the endothelium in cardiovascular pathophysiology. Nat Clin Pract Cardiovasc Med, 2009, 6(1): 16-26.
32. Traub O, Berk B C. Laminar shear stress: mechanisms by which endothelial cells transduce an atheroprotective force. Arterioscler Thromb Vasc Biol, 1998, 18(5): 677-685.
33. Chatzizisis Y S, Coskun A U, Jonas M, et al. Role of endothelial shear stress in the natural history of coronary atherosclerosis and vascular remodeling. J Am Coll Cardiol, 2007, 49(25): 2379-2393.
34. Chiu J J, Chien S. Effects of disturbed flow on vascular endothelium: pathophysiological basis and clinical perspectives. Physiol Rev, 2011, 91(1): 327-387.
35. Guo Ziyi, Yan Zhiqiang, Bai Ling, et al. Flow shear stress affects macromolecular accumulation through modulation of internal elastic lamina fenestrae. Clin Biomech, 2008, 23: S104-S111.
36. Lehoux S, Castier Y, Tedgui A. Molecular mechanisms of the vascular responses to hemodynamic forces. J Intern Med, 2006, 259(4): 381-392.
37. Berk B C, Korshunov V A. Genetic determinants of vascular remodeling. Can J Cardiol, 2006, 22: 6B-11B.
38. Golledge J. Abdominal aortic aneurysm: update on pathogenesis and medical treatments. Nat Rev Cardiol, 2019, 16(4): 225-242.
39. Dua M M, Dalman R L. Hemodynamic influences on abdominal aortic aneurysm disease: application of biomechanics to aneurysm pathophysiology. Vascul Pharmacol, 2010, 53(1/2): 11-21.
40. Boussel L, Rayz V, Mcculloch C, et al. Aneurysm growth occurs at region of low wall shear stress: patient-specific correlation of hemodynamics and growth in a longitudinal study. Stroke, 2008, 39(11): 2997-3002.
41. 姜宗来, 齐颖新. 血管力学生物学. 上海: 上海交通大学出版社, 2017: 128.
42. Doyle B J, Callanan A, Burke P E, et al. Vessel asymmetry as an additional diagnostic tool in the assessment of abdominal aortic aneurysms. J Vasc Surg, 2009, 49(2): 443-454.
43. Drzisga D, Köppl T, Pohl U, et al. Numerical modeling of compensation mechanisms for peripheral arterial stenoses. Comput Biol Med, 2016, 70: 190-201.
44. Heil M, Schaper W. Influence of mechanical, cellular, and molecular factors on collateral artery growth. Circ Res, 2004, 95(5): 449-458.

Journal of Biomedical Engineering

Effect of lower limb amputation level on aortic hemodynamics: a numerical study

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