FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Estudo farmacolÃgico do Ãleo essencial de Croton nepetaefolius Baill. sobre o mÃsculo liso traqueal e vascular e sobre as propriedades eletrofisiolÃgicas de neurÃnios fÃsicos de gÃnglio celÃaco. Pedro Jorge Caldas MagalhÃes, Tese de Doutorado em Farmacologia, UFC, 2002. Croton nepetaefolius Baill à um arbusto aromÃtico do Nordeste brasileiro, conhecido como âmarmeleiro sabiÃâ, utilizado na medicina popular como antiespasmÃdico e carminativo. Os principais constituintes do seu Ãleo essencial sÃo 1,8-cineol, metil-eugenol, xantoxilina e terpineol. Recentemente, demonstraram-se propriedades antiespasmÃdica intestinal, hipotensiva, antiinflamatÃria e analgÃsica para o Ãleo essencial do Croton nepetaefolius (OECN). Neste trabalho, caracterizamos os efeitos farmacolÃgicos do OECN sobre o mÃsculo liso respiratÃrio e vascular de rato e cobaio e sobre o funcionamento elÃtrico de neurÃnios de gÃnglio celÃaco de cobaio. Usamos preparaÃÃes in vitro de vasos sanguÃneos de ratos e cobaios machos (aorta e vasos mesentÃricos) e anÃis de traquÃia, mantidos em soluÃÃo nutridora, aerada, pH 7,4, a 37 oC, para registro isomÃtrico das contraÃÃes musculares. Usamos tambÃm gÃnglios celÃacos intactos de cobaios, mantidos em temperatura ambiente in vitro, para os registros eletrofisiolÃgicos pela tÃcnica do microeletrodo intracelular. In vivo, avaliamos as aÃÃes do OECN sobre a pressÃo arterial mÃdia e alguns parÃmetros cardÃacos, respiratÃrios e hematolÃgicos em ratos. O OECN (0,1 - 1000 microgrma/ml) relaxou o tÃnus basal (5 mM [K+]) e o tÃnus aumentado por K+ (60 mM) em traquÃia de cobaio, de maneira dependente de concentraÃÃo (CE50 de 4 e 63 micrograma/ml, respectivamente). Em tecidos de cobaios previamente sensibilizados, o OECN (300 e 600 micrograma/ml), reduziu a contraÃÃo induzida pela apresentaÃÃo do antÃgeno sensibilizante (ovalbumina). Na faixa de concentraÃÃo de 100 a 400 micrograma/ml, bloqueou as contraÃÃes induzidas por histamina e PGF2 alfa. O OECN inibiu as contraÃÃes induzidas por histamina, carbacol e KCl com CI50 na faixa de 100 - 130 micrograma/ml. Em aorta de rato e cobaio, relaxou a contraÃÃo induzida por 60 mM de K+ (CI50 de 32 e 200 micrograma/ml, respectivamente). Em rato, mas nÃo em cobaio, este relaxamento foi parcialmente inibido pela retirada do endotÃlio vascular ou pela adiÃÃo de 100 micrograma M de L-NAME. Em aorta de cobaio, o OECN inibiu as contraÃÃes independentes de Ca2+, induzidas por dibutirato de forbol e por K+ hiperosmolar na soluÃÃo nutridora. O OECN diminuiu preferencialmente a pressÃo arterial em ratos DOCA-sal do que em ratos nefrectomizados e, bloqueou mais potentemente as contraÃÃes induzidas pela fenilefrina em aorta de rato DOCA do que dos animais nefrectomizados. O OECN, metil-eugenol e terpineol, aumentam o fluxo de lÃquido pela circulaÃÃo mesentÃrica de rato, sendo este efeito parcialmente inibido pela presenÃa de L-NAME. Em nenhuma dessas preparaÃÃes o OECN produziu hiperpolarizaÃÃo do potencial transmembrana. Em neurÃnios fÃsicos de gÃnglio celÃaco de cobaio, o OECN diminuiu significativamente o aumento da excitabilidade produzido pela histamina sem alterar as propriedades passivas e ativas dos neurÃnios. Em conclusÃo, o OECN relaxa o mÃsculo liso das vias aÃreas, à um agente hipotensor e vasorelaxante e diminui a excitabilidade induzida por histamina em neurÃnios autonÃmicos. Seus efeitos sÃo, provavelmente, intracelulares ou mediados por proteÃna quinase C. / Croton nepetaefolius is an aromatic bush found in brazilian Northeast region, called âmarmeleiro sabiÃâ, and it is used in folk medicine as an antispasmodic and carminative agent. Its essential oil is comprised of 1,8-cineole, methyl-eugenol, xanthoxylin, terpineol and others constituents. Recent studies showed some pharmacological activities of the essential oil of Croton nepetaefolius (EOCN) as an intestinal antispasmodic, hypotensive, anti-inflammatory and analgesic agent. Our aim in this work was to evaluate the effects of EOCN on airway and vascular smooth muscle and also on autonomic neurons. We used in vitro models of rat and guinea-pig isolated vessels and guinea-pig tracheal rings for isometric recording of the smooth muscle contractions. Guinea-pig celiac ganglion, was used for intracellular microelectrode recording of electricophysiological signals. Moreover, mean arterial pressure, cardiovascular, respiratory and hematologic parameters were measured in vivo in rats. EOCN (0,1 â 1000 microgram/ml) relaxed basal and K+-increased guinea-pig tracheal tonus (EC50 = 4 and 63 microgram/ml, respectively), in a concentratation-dependent manner. In ovalbumin-sensitized guinea-pig tissues, EOCN inhibited the antigen-induced contraction. EOCN (100 - 400 microgram/ml) blocked the histamine- and PGF2alpha -induced contractions. The contractions induced by histamine, carbacol and KCl were inhibited by EOCN with IC50s between 100-130 microgram/ml. In rat and guinea-pig aortic rings, EOCN relaxed the 60 mM K+-induced contractions (IC50 = 32 and 200 microgram/ml, respectively). Only in rat tissues, this EOCN-induced relaxation was partially inhibited by both L-NAME (100 microgram M) or endothelium lack. In guinea-pig aortic rings, EOCN inhibited the Ca2+-independent phorbol esther- and hyperosmotic K+- induced contractions. EOCN, preferably, diminished the mean arterial pressure and inhibited the aortic rings phenylephrine-induced contractions in DOCA-salt treated rats rather than uninephrectomized rats. Both EOCN, methyl-eugenol and terpineol increased the flow through rat mesenteric bed. This effect was partially blocked by L-NAME (50 microgram M). EOCN did not produce hyperpolarization of the transmembrane potential. In celiac ganglion phasic neurons, EOCN signicantly inhibited the histamine-induced increase of the neuronal excitability. In conclusion, EOCN is an airway smooth muscle relaxant, hypotensor and vasorelaxant agent, and it is a blocker of the stimulant histamine activity on autonomic neurons. Its effects are, probably, mediated by an intracellular action or protein C kinase modulation.

Trinta dias após a indução do diabetes, em aortas com endotélio (E+) de ratas diabéticas (DB), a Rmáx ao cloreto de potássio (KCl) foi reduzida e a resposta à noradrenalina (NA) foi semelhante as controles (CT). A retirada do endotélio (E-) potencializou a resposta ao KCl e NA, porém essa potencialização foi de menor magnitude em DB. A Rmáx à NA em aortas E+: não foi alterada após o seqüestro de ânion superóxido ou inibição da síntese de óxido nítrico (NO) em DB, nas CT esta resposta foi reduzida e aumentada, respectivamente, e foi reduzida apenas nas DB após o bloqueio dos receptores para endotelina (ET). A mobilização de cálcio (Ca2+) em resposta à NA foi reduzida em aorta E+ e E- de DB. Em aortas de ratas diabéticas, as alterações no aparato contrátil, como por exemplo. A redução da mobilização de Ca2+, podem ser responsáveis pela redução da resposta contrátil e a redução da modulação do NO sobre a resposta à NA ou o aumento da liberação de ET pelo endotélio podem ser os responsáveis pela manutenção da resposta à NA. / Thirty days after induction of diabetes, in aortas with endothelium (E+) of diabetic female rats (DB), the maximum response (Rmax) to potassium chloride (KCl) was reduced and the Rmax to noradrenaline (NE) was similar to controls (CT). The endothelium (E-) removal increased the response to KCl and NE, but this increase was of a lower magnitude in DB than in CT. In aortas E+, the Rmax to NA: was not altered by superoxide anion scavenger or nitric oxide (NO) synthesis inhibition in DB, whereas in CT this response is reduced or increased, respectively, and was reduced only in DB after endothelin (ET) receptor blockade. The mobilization of the calcium (Ca2+) in response to NE was reduced in aortas E+ and E- of the DB. In aortas of DB, the alterations in the contractile apparatus, for example, reduction of the Ca2+ mobilization may be responsible for the reduction of the vasoconstriction. The reduction of NO modulation upon the response to NE or the increase of the ET release can be the responsible for the maintenance of the contractile response to NE.

Pacientes sépticos podem evoluir para choque séptico, destes 40% sobrevivem. Caracterizamos o modelo experimental, avaliamos fatores envolvidos na inflamação e avaliamos a modulação causada por purinas (ATP/ADP) na quantificação de superóxido (O2-) e na reatividade vascular da aorta isolada. Os resultados sugerem que na aorta isolada de animais endotoxêmicos, ATP e ADP aumentam a síntese de óxido nítrico (NO), porém somente o ATP reduz a biodisponibilidade de O2-, provavelmente pelo reacoplamento da NO sintase endotelial / Septic patients can evolve for septic shock and 40% of these survive. We characterize the experimental model we evaluate involved factors in the inflammation and evaluate the modulation caused by purines (ATP/ADP) in the superoxide quantification (O2-) and in the vascular reactivity of isolated aorta. The results suggest that in isolated aorta of endotoxemics rats, ATP and ADP increase the endothelial nitric oxide synthase (NOS) however just ATP reduces the bio availability of O2-, probably for the re-couples of the endothelial NOS synthase

Objectifs : caractériser (1) la morphométrie de la crosse afin d’examiner les critères favorisant les complications et la faisabilité d’endoprothèses (EP) standards. (2) les propriétés mécaniques de l’aorte ascendante (AA) chez le porc, homme sain et en cas de dissection aortique (DAo).Matériels et méthodes :Caractérisation morphométrique : A partir d’angioscanner aortiques les paramètres: (1) morphométriques élémentaires (2) géométriques ; (3) troncs supra-aortiques (TSAo), sont mesurésCaractérisation mécanique : In vivo : à partir de données échographiques et hémodynamiques, les paramètres élastiques sont calculés.In vitro : tests de traction bi-axiale sur l’AA plus une analyse histomorphométrique et microstructurale.Résultats :Caractérisation morphométrique : > de75% des patients ont une orientation des TSAo à ± 15° par rapport à la moyenne, et une variabilité de la distance entre les ostia TSAo de ± 4 mm.Les facteurs indépendants associés aux endofuites, défaut d’apposition et mal-positionnement sont respectivement:(1) collet proximal court; (2) angulation de la zone d’ancrage (valeur seuil 51°); et (3) indice tortuosité (valeur seuil 1.68) Caractérisation mécanique : In vivo : une grande compliance de l’aorte porcine comparé à l’homme et une rigidification en cas de DAo.In vitro : l’aorte porcine a un comportement linéaire comparé au caractère non linéaire chez l’homme. Conclusion : Ce travail montre :- le lien entre morphométrie et complications après EP, et la faisabilité d’EP standards pour la crosse.- le modèle porcin est inapproprié pour tester les EP de l’AA. - la rigidification de la paroi en cas de DAo influencera le choix des futurs EP. / Objectives: characterize (1) arch morphometry to examine criteria favoring complications after thoracic endovascular aortic repair (TEVAR) and feasibility of « off-the-shelf » fenestrated devices.(2) mechanical properties of ascending aorta (AA) in swine and humans, with and without aortic dissection.Materials and methods : Morphometric characterization : Computed tomographic angiography were analysed to calculate elementary morphometric, geometric and supra-aortic trunks data Mechanical characterization : In vivo: arterial pressure and diameters measured with echocardiophy are used to calculate elastic parameters.Ex vivo: biaxial tensile testing performed on AA plus histological and microstructural analysis. Results :Morphometric characterization : In > 75% of cases supra-aortic branches are positioned within 15° of each other and distances between them have a variability of ± 4 mm.Independant factors associated with endoleak, bird beak and mis-positioning are respectively : (1) short proximal neck (2) landing zone angulation (cut-off value: 51°); and (3) tortuosity index (cut-off value: 1.68). Mechanical characterization : in vivo: greater compliance of swine aorta compared to humans and a stiffer aorta in case of aortic dissectionBiaxial testing: linear stress-strain behavior of swine aorta, compared to a non linear one in human. Conclusion : our study reveals :- the impact of anatomy on complications occurrence after TEVAR, and suitable arguments for « off-the-shelf » fenestrated devices.- swine model is inappropriate to test AA dedicated stent-graft.- stiffer wall in aortic dissection has consequences on the choice of futur devices dedicated to AA.

Das Aortenaneurysma ist eine häufige Erkrankung, welche mit der gravierenden Kompli-kation einer Aortenruptur einhergehen kann. In den letzten 20 Jahren konnten beachtliche kurative Fortschritte erzielt werden, welche u.a. auf die Ergänzung der rein operativen Therapie um endovaskuläre und Hybridverfahren zurückzuführen sind. Dennoch ist die Aneurysmaruptur mit einer außerordentlich hohen Mortalität assoziiert. Die Genese des Aortenaneurysmas ist multifaktoriell bedingt, sodass das Wachstumsverhalten der Aorta als Surrogat des realen Rupturrisikos schwer vorherzusagen ist. Im klinischen Alltag findet überwiegend der maximale Diameter als Größen- und Verlaufsparameter Anwendung, obwohl dadurch den heterogenen Veränderungen der Aorta möglicherweise nicht ausrei-chend Rechnung getragen wird. Ziel der Studie war es, anhand einer CT-gestützten Verlaufsquantifizierung von Aorten-veränderungen Prädiktoren für das Wachstum der Aorta abzuleiten und Wachstumsraten auf Basis unterschiedlicher morphologischer Ausgangsgrößen zu vergleichen. Zwischen den definierten Aortensegmenten konnten signifikante Unterschiede der erho-benen morphologischen Parameter wie beispielsweise der Größe, der Verteilung von Ge-fäßwand und –lumen, der Verkalkung und der Krümmung aufgezeigt werden. Diese Heterogenität ließ sich auch beim Vergleich von thorakalen/abdominalen, aneurysmati-schen/nicht aneurysmatischen und wachsenden/nicht wachsenden Segmenten bestätigen. So waren beispielweise wachsende Aortensegmente initial größer als nicht wachsende (Volumen 82 cm³ vs. 53 cm³, p < 0,00; Diameter 36 mm vs. 30 mm, p< 0,00), unterschie-den sich hingegen aber nicht hinsichtlich der Wandverkalkung (Calcium-Score 894 vs. 842, p = 0,77). Im Verlauf wiesen die wachsenden Segmente unter anderem eine stärkere Zunahme der maximalen Wandstärke (+15 % vs. +4 %, p > 0,00) und eine stärkere Elongationstendenz (Segmentlänge +3,6 % vs. -0,5 %, p < 0,00) auf. Insgesamt konnte gezeigt werden, dass im Verlauf eine Wachstumsdynamik beinahe aller erhobenen Größen bestand. Ein durchschnittliches Wachstum des Aortensegmentvolumens um 5,7 % pro Jahr gezeigt konnte werden. Unter den potentiellen Einflussfaktorenkonnten konnten als relevante Prädiktoren die ma-ximale Wandstärke, die Diameter-Längen-Ratio, die Exzentrizität der Außenzirkumferenz sowie die Risikofaktoren Rauchen und die Einnahme von Kortikoiden identifiziert wer-den. Der Vergleich morphologisch unterschiedlich basierter Wachstumsraten zeigte eine erhebliche Diskrepanz insbesondere zwischen dem Routineparameter maximaler Diameter und dem sensitiveren Volumen. Schlussfolgerung: CT-morphologisch bestimmbare Parameter wie die Wandstärke, das Proportionsmaß Diameter-Längen-Ratio und die Exzentrizität des Gefäßquerschnittes sind Prädiktoren überdurchschnittlichen Aortenwachstums. Die umfassenden routinemäßige Evaluation der Aorta mit Erhebung mehrerer morphologischer Parameter – insbesondere des Volumens – ist notwendig, um das heterogene und multifaktoriell bedingte Wachstum der Aorta suffizient zu erfassen.:Inhalt Inhalt I Bibliographische Beschreibung V Referat V Abbildungsverzeichnis VI Tabellenverzeichnis VII 1. Einführung 1 1.1. Zur Historie des Aneurysmas 1 1.1.1. Erste Erwähnungen und Altertum 1 1.1.2. Mittelalter und Renaissance– von außen nach innen 2 1.1.3. Neuzeit – Evolution pathogenetischer Erkenntnisse und suffizienter Therapien 3 1.2. Begriffsbestimmung 5 1.2.1. Aneurysma verum 5 1.2.2. Aneurysma dissecans 6 1.2.3. Aneurysma spurium 6 1.3. Ätiologie und Einflussfaktoren der Aneurysmaentstehung 6 1.3.1. Pathophysiologische Aspekte der Aneurysmagenese 7 1.3.2. Genetische Syndrome als Ursache von Aortenaneurysmen 9 1.3.3. Gefäßassoziierte Pathologien als Ursache für Aortenaneurysmen 11 1.3.4. Risikofaktoren für die Entstehung aortaler Aneurysmen 13 1.3.5. Medikamentöse Wechselwirkungen 15 1.4. Epidemiologie des Aortenaneurysmas 17 1.4.1. Angaben zur Prävalenz und Inzidenz 17 1.4.2. Rupturraten von thorakalen und abdominellen Aneurysmen 18 1.4.3. Angaben zu Wachstumsraten (GRy) aortaler Aneurysmen 19 1.5. Diagnostik und Bildgebung der Aorta 21 1.5.1. Nichtapparative Diagnostik 21 1.5.2. Konventionelles Röntgen und Angiografie 21 1.5.3. Ultraschall 21 1.5.4. Schnittbildgebung – Computer- und Magnetresonanztomografie (CT/MRT) 22 1.6. Therapeutische Optionen 23 1.6.1. Thorakale und thorakoabdominelle Aortenaneurysmen 23 1.6.2. Bauchaortenaneurysmen 23 2. Ziel der Studie 25 3. Materialien und Methoden 26 3.1. Studienkollektiv – Ein- und Ausschlusskriterien 26 3.2. Bildgebung 26 3.3. Bildverarbeitung und Messverfahren 27 3.3.1. Vorbereitung 27 3.3.2. Volumenberechnung 30 3.3.3. Messung von Diameter und Querschnittsfläche 30 3.3.4. Berechnung der Innen- und Außenfläche 31 3.3.5. Messung der minimalen und maximalen Wandstärke 32 3.3.6. Bestimmung der Segmentlänge 32 3.3.7. Winkelungs- und Krümmungsmessung 33 3.3.8. Exzentrizität des Gefäßquerschnittes 33 3.3.9. Vermessung der Gefäßwandverkalkung 34 3.4. Klinisch-anamnestische Faktoren 36 3.5. Berechnung der Wachstumsraten 36 3.6. Definition des Wachstumskriteriums 37 3.7. Gruppierung der Aortensegmente zur Auswertung 37 3.8. Statistische Auswertung 38 3.8.1. Mittelwertdifferenzen 38 3.8.2. Korrelation 38 3.8.3. Multiple Regressionsanalyse 38 3.8.4. Messmethodenvergleich 39 4. Ergebnisse 40 4.1. Charakteristika der Studienpopulation 40 4.1.1. Patientcharakteristika 40 4.1.2. Verteilung der klinischen Risikofaktoren 41 4.2. Quantifizierung der Aortenveränderungen anhand CT-morphologischer Parameter – initial und im Verlauf 43 4.2.1. Volumen 43 4.2.2. Diameter und Querschnittsfläche 47 4.2.3. Innen- und Außenfläche 48 4.2.4. Wandstärke 49 4.2.5. Länge, Proportion und Krümmung 52 4.2.6. Exzentrizität der Gefäßquerschnitte 55 4.2.7. Wandverkalkung 57 4.3. Einflussfaktoren des Aortenwachstums 62 4.3.1. Korrelationsanalyse der potentiellen Einflussfaktoren mit dem Wachstumskriterium 62 4.3.2. Prädiktoren des Aortenwachstums - Multiple Regressionsanalyse 67 4.4. Diskrepanzen zwischen unterschiedlich basierten Wachstumsraten 70 5. Diskussion 73 5.1. Wachstumsverhalten und Aortenmorphologie 73 5.1.1. Das Volumen als sensitiver Verlaufsparameter des Aortenwachstums 73 5.1.2. Etablierte Größen: Diameter und Querschnittsfläche 75 5.1.3. Alternative dreidimensionale Parameter: Innen- und Außenfläche 76 5.1.4. Die aortale Wandstärke als Surrogatparameter für intraluminalen Thrombus und atheromatöse Wandveränderungen 77 5.1.5. Die segementale Länge, Proportion und Krümmung als Korrelat longitudinalen Wachstums 78 5.1.6. Die Exzentrizität der Gefäßquerschnitte 79 5.1.7. Die aortale Wandverkalkung 80 5.2. Prädiktoren und Einflussfaktoren des Aortenwachstums 80 5.2.1. Initiale Größe 81 5.2.2. Gefäßwandveränderungen 82 5.2.3. Das Verhältnis von Proportion, Krümmung und Elongation der Aorten-segmente 84 5.2.4. Die Morphologie des Gefäßquerschnittes 86 5.2.5. Die Rolle der aortalen Wandverkalkung für das Aortenwachstum 87 5.2.6. Die Relevanz klinischer Risikofaktoren 87 5.3. Diskrepanzen der unterschiedlich basierten Wachstumsraten 89 5.4. Limitationen der Studie 91 5.5. Schlussfolgerung 92 6. Zusammenfassung der Arbeit 93 7. Literaturverzeichnis 95 8. Erklärung zur Dissertation 118 9. Curriculum Vitae 119 Persönliche Daten 119 Ausbildung 119 Praktische Erfahrungen und beruflicher Werdegang 119 10. Danksagung 121 / Purpose This study aims to identify clinical and CT-morphologic predictors of growth of the native aorta and aortic aneurysms. Material and methods Seventy-three patients (66 ±8.0 years) who underwent two subsequent computed tomography angiographies of the thoracic/thoracoabdominal/abdominal aorta for clinical reasons from 2002 - 2008 were retrospectively included. The mean interval between the CT scans was 1.8 ±0.8 years. The aortic anatomy was divided into 9 segments from sinotubular junction to iliac bifurcation. CT scans were obtained with 16- and 64-slice scanners, all series were analyzed on a commercially available workstation. Beside the collection of information about the past medical history, several morphologic parameters were measured for each segment such as aortic volume, maximum diameter, cross sectional area, surface area, calcification, tortuosity, wall thickness or cross sectional eccentricity. Annual growth rates were calculated for each parameter. Aortic total volume was considered as the standard of reference. Therefore, aortic growth was defined as a growth rate of total volume > 5 %. Multiple regression analysis was conducted to reveal predictors of aortic growth. Results For all segments, average volumes were 65.0 ± 59.0/44.7 ± 39.6/20.3 ± 27.9 cm³ (total/lumen/wall). The annual aortic growth rate of total volume was 5.7 % for all segments. All parameters that represent the initial size of the aortic segments (total and lumen volume, maximum diameter, cross sectional area, surface area) were approved as predictors of aortic growth. Further predictors were wall volume, maximum and minimum wall thickness, diameter length ratio, segmental length and tortuosity index. Among the clinical parameters, smoking, corticosteroid medication and peripheral artery disease were confirmed as aortic growth predictors. Conclusions In clinical routine, most therapeutic decisions a made based on the diameter measurement alone, which might be inappropriate. A comprehensive evaluation of aortic morphology is warranted in the presence of increased aortic size, wall thickness, cross sectional eccentricity, smoking and corticosteroid therapy.:Inhalt Inhalt I Bibliographische Beschreibung V Referat V Abbildungsverzeichnis VI Tabellenverzeichnis VII 1. Einführung 1 1.1. Zur Historie des Aneurysmas 1 1.1.1. Erste Erwähnungen und Altertum 1 1.1.2. Mittelalter und Renaissance– von außen nach innen 2 1.1.3. Neuzeit – Evolution pathogenetischer Erkenntnisse und suffizienter Therapien 3 1.2. Begriffsbestimmung 5 1.2.1. Aneurysma verum 5 1.2.2. Aneurysma dissecans 6 1.2.3. Aneurysma spurium 6 1.3. Ätiologie und Einflussfaktoren der Aneurysmaentstehung 6 1.3.1. Pathophysiologische Aspekte der Aneurysmagenese 7 1.3.2. Genetische Syndrome als Ursache von Aortenaneurysmen 9 1.3.3. Gefäßassoziierte Pathologien als Ursache für Aortenaneurysmen 11 1.3.4. Risikofaktoren für die Entstehung aortaler Aneurysmen 13 1.3.5. Medikamentöse Wechselwirkungen 15 1.4. Epidemiologie des Aortenaneurysmas 17 1.4.1. Angaben zur Prävalenz und Inzidenz 17 1.4.2. Rupturraten von thorakalen und abdominellen Aneurysmen 18 1.4.3. Angaben zu Wachstumsraten (GRy) aortaler Aneurysmen 19 1.5. Diagnostik und Bildgebung der Aorta 21 1.5.1. Nichtapparative Diagnostik 21 1.5.2. Konventionelles Röntgen und Angiografie 21 1.5.3. Ultraschall 21 1.5.4. Schnittbildgebung – Computer- und Magnetresonanztomografie (CT/MRT) 22 1.6. Therapeutische Optionen 23 1.6.1. Thorakale und thorakoabdominelle Aortenaneurysmen 23 1.6.2. Bauchaortenaneurysmen 23 2. Ziel der Studie 25 3. Materialien und Methoden 26 3.1. Studienkollektiv – Ein- und Ausschlusskriterien 26 3.2. Bildgebung 26 3.3. Bildverarbeitung und Messverfahren 27 3.3.1. Vorbereitung 27 3.3.2. Volumenberechnung 30 3.3.3. Messung von Diameter und Querschnittsfläche 30 3.3.4. Berechnung der Innen- und Außenfläche 31 3.3.5. Messung der minimalen und maximalen Wandstärke 32 3.3.6. Bestimmung der Segmentlänge 32 3.3.7. Winkelungs- und Krümmungsmessung 33 3.3.8. Exzentrizität des Gefäßquerschnittes 33 3.3.9. Vermessung der Gefäßwandverkalkung 34 3.4. Klinisch-anamnestische Faktoren 36 3.5. Berechnung der Wachstumsraten 36 3.6. Definition des Wachstumskriteriums 37 3.7. Gruppierung der Aortensegmente zur Auswertung 37 3.8. Statistische Auswertung 38 3.8.1. Mittelwertdifferenzen 38 3.8.2. Korrelation 38 3.8.3. Multiple Regressionsanalyse 38 3.8.4. Messmethodenvergleich 39 4. Ergebnisse 40 4.1. Charakteristika der Studienpopulation 40 4.1.1. Patientcharakteristika 40 4.1.2. Verteilung der klinischen Risikofaktoren 41 4.2. Quantifizierung der Aortenveränderungen anhand CT-morphologischer Parameter – initial und im Verlauf 43 4.2.1. Volumen 43 4.2.2. Diameter und Querschnittsfläche 47 4.2.3. Innen- und Außenfläche 48 4.2.4. Wandstärke 49 4.2.5. Länge, Proportion und Krümmung 52 4.2.6. Exzentrizität der Gefäßquerschnitte 55 4.2.7. Wandverkalkung 57 4.3. Einflussfaktoren des Aortenwachstums 62 4.3.1. Korrelationsanalyse der potentiellen Einflussfaktoren mit dem Wachstumskriterium 62 4.3.2. Prädiktoren des Aortenwachstums - Multiple Regressionsanalyse 67 4.4. Diskrepanzen zwischen unterschiedlich basierten Wachstumsraten 70 5. Diskussion 73 5.1. Wachstumsverhalten und Aortenmorphologie 73 5.1.1. Das Volumen als sensitiver Verlaufsparameter des Aortenwachstums 73 5.1.2. Etablierte Größen: Diameter und Querschnittsfläche 75 5.1.3. Alternative dreidimensionale Parameter: Innen- und Außenfläche 76 5.1.4. Die aortale Wandstärke als Surrogatparameter für intraluminalen Thrombus und atheromatöse Wandveränderungen 77 5.1.5. Die segementale Länge, Proportion und Krümmung als Korrelat longitudinalen Wachstums 78 5.1.6. Die Exzentrizität der Gefäßquerschnitte 79 5.1.7. Die aortale Wandverkalkung 80 5.2. Prädiktoren und Einflussfaktoren des Aortenwachstums 80 5.2.1. Initiale Größe 81 5.2.2. Gefäßwandveränderungen 82 5.2.3. Das Verhältnis von Proportion, Krümmung und Elongation der Aorten-segmente 84 5.2.4. Die Morphologie des Gefäßquerschnittes 86 5.2.5. Die Rolle der aortalen Wandverkalkung für das Aortenwachstum 87 5.2.6. Die Relevanz klinischer Risikofaktoren 87 5.3. Diskrepanzen der unterschiedlich basierten Wachstumsraten 89 5.4. Limitationen der Studie 91 5.5. Schlussfolgerung 92 6. Zusammenfassung der Arbeit 93 7. Literaturverzeichnis 95 8. Erklärung zur Dissertation 118 9. Curriculum Vitae 119 Persönliche Daten 119 Ausbildung 119 Praktische Erfahrungen und beruflicher Werdegang 119 10. Danksagung 121

[pt] Com o objetivo de demonstrar as possibilidades oferecidas pelas tecnologias tridimensionais, no entendimento das doenças cardíacas e testar tratamentos inovadores, o presente estudo obteve imagens da região torácica de um paciente utilizando tomografia computadorizada multi-fatias. Essas imagens foram tratadas, para selecionar apenas a região de interesse, obtendo-se um modelo tridimensional digital da aorta torácica e tóraco-abdominal. A partir daí, foram confeccionados uma serie de modelos físicos, com a utilização da manufatura aditiva, e testados com diversos materiais para simular a estrutura elástica deste vaso. Após a construção dos modelos físicos, as imagens obtidas foram processadas e renderizadas e um modelo de simulação virtual foi criado para testar procedimentos minimamente invasivo. O uso de imagens da Tomografia Computadorizada, transformadas em modelos matemáticos virtuais e posteriormente em representação física, através da tecnologia aditiva, expande as possibilidades didáticas do ensino medico e possibilitam simular práticas e procedimentos cardiológicos minimamente invasivos. / [en] In order to demonstrate the possibilities provided by three-dimensional technologies, to understand disease states and test innovative treatments, this study obtained images of the thoracic region of a patient using multi-slice Computerized Tomography (CT). These images were handled to select only the region of interest, obtaining a three-dimensional digital model of thoraco-abdominal and thoracic aorta. Thereafter, a series of physical models were made using additive manufacturing and thoroughly tested on materials to simulate the elastic structure of the vessel. After building up physical models, the images were processed and rendered, and a virtual simulation model was created to test minimally invasive procedures. The CT s images transformed into virtual mathematical models and later in physical representation, by additive technology, expand educational opportunities and enable simulation of minimally invasive cardiological procedure.

[pt] Doenças cardiovasculares são responsáveis por um elevado número de óbitos em seres humanos. Muitas dessas patologias são dependentes do ciclo cardíaco e estão localizadas na aorta, a maior e principal artéria do nosso corpo. O conhecimento dos padrões de escoamento e distribuições de tensões nas paredes da aorta podem auxiliar no diagnóstico e prevenção de algumas dessas doenças. Dessa forma, estudou-se numericamente o escoamento do sangue, durante o ciclo cardíaco, em um modelo 3D da aorta de um paciente específico, após a implantação de TAVI (Transcatheter Aortic Valve Implantation). O ciclo cardíaco é formado por dois períodos chamados de sístole e diástole. Durante a sístole, sangue é bombeado do coração para a aorta, apresentado altos valores de vazão, resultando em escoamento turbulento. Por outro lado, na diástole, com o fechamento da válvula aórtica, o sangue escoa com baixas velocidades em regime laminar. Até hoje, cientistas enfrentam um desafio na modelagem da turbulência, pois não existe uma única modelagem que forneça previsibilidade para todas as situações envolvendo o regime turbulento, com esforço computacional razoável. Para seleção do modelo de turbulência mais adequado para análise do escoamento no interior da aorta, na presença da transição de regimes de escoamento durante o ciclo cardíaco, com um custo razoável, selecionou-se a metodologia baseada na Média de Reynolds. Diferentes modelos foram comparados com dados experimentais extraídos do mesmo modelo aórtico em escala real, porém em regime permanente, com vazão correspondente ao pico da sístole. Por fim, avaliou-se o impacto das condições de contorno e dos modelos de turbulência durante o ciclo cardíaco na distribuição e valores de tensões e grandezas turbulentas no endotélio vascular. Mostrou-se que a distribuição espacial das médias temporais de tensão foram qualitativamente e quantitativamente similares, para os dois ciclos cardíacos representativos de diferentes pacientes, porém com pequenas mudanças locais para cada caso. Em termos dos modelos de turbulência, observou-se que o modelo SAS (Scale Adaptive Simulation) foi capaz de representar a relaminarização do escoamento sanguíneo no período diastólico. / [en] Cardiovascular diseases are responsible for a high number of deaths in humans. Many of these pathologies are dependent on the cardiac cycle and are located in the aorta, the largest and main artery in our body. Knowledge of flow patterns and stress distributions in the walls of the aorta can help in the diagnosis and prevention of some of these diseases. Thus, the flow of blood during the cardiac cycle was numerically studied in a 3D model of the aorta of a specific patient, after TAVI (Transcatheter Aortic Valve Implantation) implantation. The cardiac cycle consists of two periods called systole and diastole. During the systole, blood is pumped from the heart to the aorta, presenting high flow rates, resulting in a turbulent flow. On the other hand, in diastole, with the closure of the aortic valve, the blood flows with low velocities in laminar regime. Until today, scientists face a challenge in turbulence modeling, as there is no single model that provides predictability for all situations involving the turbulent regime, with reasonable computational effort. In order to select the most suitable turbulence model for the analysis of the flow inside the aorta, in the presence of the transition of flow regimes during the cardiac cycle, with a reasonable cost, the methodology based on the Reynolds Average was selected. Different models were compared with experimental data extracted from the same real-scale aortic model, but a in steady state, with flow corresponding to the systolic peak. Finally, the impact of boundary conditions and turbulence models during the cardiac cycle on the distribution and values of stresses and turbulent quantities in the vascular endothelium were evaluated. It was shown that the spatial distribution of the temporal averages of tension was qualitatively and quantitatively similar, for the two cardiac cycles representative of different patients, but with small local changes for each case. In terms of turbulence models, it was observed that the SAS (Scale Adaptive Simulation) model was able to represent the relaminarization of blood flow in the diastolic period.

Thesis (MScMedSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Introduction: Nitric oxide (NO) is an important chemical messenger in the cardiovascular system. Despite considerable progress in this field, there remains an on-going need for affordable and user-friendly NO measurement techniques. Therefore, in this study we aimed to develop and characterise NO-detection techniques not previously used in our laboratory, and, in addition, characterise an ex vivo method to measure the functional effects of the endothelium and NO production in the vasculature. Methods: Three different NO-detection techniques were compared: (i) Amperometric NO sensors. Here, NO-increasing effects of known NO synthase (NOS) activators were investigated (insulin, acetylcholine and biosynthetic human insulin). Three different NO sensors were evaluated on cultured endothelial cells and aortic tissue. Putative NOincreasing effects of shear stress were also investigated; (ii) Nitrite (NO2 -) + nitrate (NO3 -) sensors. Here, I aimed to measure NO release from cultured endothelial cells; (iii) Colorimetric NO2 - measurement assay with the Griess reagent. Here, NO2 - production by endothelial cells was measured with a plate reader. In the second part of the study an organ bath - isometric tension technique was established to measure endothelium-dependent function of aortic rings. Functional differences in aortic rings isolated from diet-induced obese rats compared to lean rats were investigated. Ring contraction was induced with phenylephrine and relaxation with acetylcholine. These investigations were further supported by western blot analyses of selected critical proteins. Lastly, the effects of perivascular adipose tissue (PVAT) on contraction and relaxation were investigated in endothelium-containing or denuded aortic ring segments. Results: Although some success was achieved with the amperometric sensors regarding calibration, any experimental results obtained were difficult to repeat due to instability of the sensors. With the NO2 -/NO3 - sensor we were not able to carry out any planned experiments due to failure to properly calibrate and standardise the sensors. Success was achieved with the Griess method. All the drugs used as positive controls (DEA/NO, fenofibrate, oleanolic acid and IL-1ß) proved to be potent inducers of NO2 - release from endothelial cells. Interestingly, the isometric tension studies showed a higher % relaxation in high fat (HF) diet aortic rings compared to those from lean animals. Western blot data showed downregulation of eNOS activation and iNOS expression in obese groups, which was suggestive of endothelial dysfunction. Interestingly, proteins associated with oxidative stress (p22phox and nitrotyrosine) were downregulated in obese groups. The presence of PVAT exerted anti-contractile effects on the rings from HF rats, however in denuded aortic rings, PVAT showed a significant pro-contractile response in both lean and HF groups. PVAT also exerted anti-relaxation effects in aortic rings from both lean and HF rats. Conclusion: We managed to successfully establish two new techniques for our laboratory (Griess method and the organ bath – isometric tension method) which can complement the more established techniques in our laboratory in order to aid us in future vascular research. Finally, the isometric tension technique used in the obese rat studies generated interesting data, which further assisted in characterising the dietinduced obesity rat model in our laboratory. / AFRIKAANSE OPSOMMING: Inleiding: Stikstofoksied (NO) is ‘n belangrike chemiese boodskapper in die kardiovaskulêre sisteem. Ondanks vordering in die veld, bestaan daar ‘n aangaande behoefte aan bekostigbare en gebruikersvriendelike NO-metingstegnieke. Gevolglik het ons in hierdie studie daarna gemik om NO-metingstegnieke wat nie vantevore in ons laboratorium beskikbaar was nie, te ontwikkel en karakteriseer. Verder het ons ten doel gehad om ‘n ex vivo model te karakteriseer om die funksionele effekte van vaskulêre endoteel en NO produksie te meet. Metodes: Drie verskillende NO-metingstegnieke was ondersoek: (i) Amperometriese NO sensors. Hier het ons die verhogende effekte op NO van bekende aktiveerders van NO sintetase (NOS) ondersoek (Insulien, asetielcholien en biosintetiese menslike insulien). Drie verskillende NO-sensors was ge-evalueer in gekultuurde endoteelselle en aortaweefsel. Die vermeende NO verhogende effekte van die wrywingskragte opgewek deur laminere vloei (“shear stress”) is ook ondersoek. (ii) Nitriet (NO2 -) + nitraat (NO3 -) sensors. Hier het ons beplan om NO-vrystelling deur gekultuurde endoteelselle te meet. (iii) Kolorimetriese meting van NO2 - met die Griess reagens. Hier het ons m.b.v. ‘n mikroplaat leser die NO2 - - vrystelling deur endoteelselle gemeet. In die tweede deel van die studie het ons ‘n orgaan bad–isometriese spanningstegniek opgestel om endoteelafhanklike funksie van aortaringe te meet. Funksionele verskille in aortaringe van vetsugtige rotte is vergelyk met kontrole rotte. Ringkontraksie is met fenielefrien geïnduseer en verslapping met asetielcholien. Hierdie ondersoeke is verder ondersteun deur Western blot analises van sleutelproteïene in die aortaweefsel. Laastens het ons die effekte van perivaskulêre vetweefsel (PVAT) op kontraksie en verslapping in aortaringe met of sonder intakte endoteel ondersoek. Resultate: Alhoewel ‘n mate van sukses behaal was met die kalibrasie van die amperometriese sensors, was eksperimentele resultate moeilik om te herhaal a.g.v. sensor-onstabiliteit. Geen eksperimente kon met die NO2 -/NO3 - sensors uitgevoer word nie weens ‘n onvermoë om ordentlike kalibrasie en standardisering uit te voer. Ons het egter wel sukses behaal met die Griess-metode. Al die middels wat as positiewe kontroles gebruik was (DEA/NO, fenofibraat, oleanoliese suur and IL-1ß) het geblyk kragtige induseerders van NO2 - produksie vanaf endoteelselle te wees. Die isometriese spanningsstudies het ‘n hoer % verslapping getoon in die hoë vet (HF) dieet aortaringe in vergelyking met die kontroles. Western blot data het ‘n afregulering van eNOS en iNOS getoon in die HF diere, wat aanduidend is van endoteel disfunksie, terwyl proteïene geassosieer met oksidatiewe stress (p22phox en nitrotirosien) afgereguleer was in die HF groep. Die aanwesigheid van PVAT het ‘n anti-kontraktiele effek gehad op die ringe van die HF groep. Toe die endoteel egter verwyder was, het PVAT in beide kontrole en HF ringe ‘n beduidende pro-kontraktiele effek gehad. Verder het PVAT ook anti-verslappingseffekte op aortaringe beide kontrole en HF rotte uitgeoefen. Gevolgtrekking: Ons het daarin geslaag om twee nuwe tegnieke vir ons laboratorium suksesvol te vestig (Griess metode en die orgaanbad-isometriese spanningstegniek) wat in die toekoms die meer gevestigde tegnieke in ons laboratorium kan komplementeer. Laastens het die isometriese spanningstegniek wat in die dieetstudies gebruik is, data opgelewer wat ons verder sal help om die vetsug model in ons laboratorium te karakteriseer.

Atherosclerosis is a disease of cardiovascular system and is usually located within large arteries. It is a major cause of death and mortality and it is related to over 12 million deaths annually affecting nearly all people in the modern world. It is a disease that involves the circulation of low density lipoproteins –LDLs (a main carrier of cholesterol) within the blood stream. These eventually accumulate in the cell wall of large and medium sized arteries to form plaques or atherosclerotic patches gradually narrow the lumen and gradually become the site of bleeding and thrombus formation. It is well known that atherosclerotic lesions in the arterial wall develop at certain sites in the human arterial system such as along the inner walls of curved segments and the outer walls of arterial bifurcations. This phenomenon is called the localization of atherosclerosis. As the early event leading to the genesis of atherosclerosis is the accumulation of atherogenic lipids such as low density lipoproteins (LDLs) within the arterial wall, mass transport between the blood and the artery wall must play an important role in the genesis and development of atherosclerosis. In the present study we investigate the correlation of luminal surface LDL concentration (cw) distribution with the distribution of wall shear stress (WSS) and the effects of both non – Newtonian behavior and pulsation of blood flow on the distributions of luminal surface LDL concentration along the wall of the human aorta. The dependence of viscosity and diffusivity and the local density are incorporated in the single and two phase flow models rendering these quantities position dependent. Then we compared the predictions of a single phase model with those of the two phases one under both steady flow and realistic pulsatile flow conditions using a human aorta model constructed from CT images. Then local hemodynamics studied by using computational fluid-dynamics (CFD) applied to realistic geometric model of the aorta. It is therefore important to solve the problem of accurately reconstructing geometric models from CT image in order to gain accuracy in CFD computations and predictions. The present numerical study revealed an adverse correlation between wall shear stress and the luminal surface LDL concentration in the aorta. The results indicate that the luminal surface LDL concentration depends not only on the local wall shear stress but also on both the global and local flow patterns. Also the results showed that under steady flow conditions, although the shear thinning non – Newtonian nature of blood could elevate wall shear stress (WSS) in most regions of the aorta, especially in areas with low wall shear stress, it had little effect on luminal surface LDL concentration (cw) in most regions of the aorta. Nevertheless, it could significantly enhance cw in areas with high luminal surface LDL concentration through the shear depended diffusivity of LDLs. The pulsation of blood flow could significantly reduce cw in these disturbed places. In conclusion the shear shining non – Newtonian nature of blood has little effect on LDL transport in most regions of the aorta, but in the atherogenic – prone areas where luminal surface LDL concentration is high its effect is apparent. Similar is the effect of pulsatile flow on the transport of LDLs. / Η αθηροσκλήρωση είναι μία νόσος του καρδιαγγειακού συστήματος και βρίσκεται συνήθως μέσα σε μεγάλες αρτηρίες. Πρόκειται για μια σημαντική αιτία θανάτου και η θνησιμότητα της σχετίζεται με πάνω από 12 εκατομμύρια θανάτους ετησίως, η οποία επηρεάζει σχεδόν όλους τους ανθρώπους στο σύγχρονο κόσμο. Είναι μια ασθένεια που περιλαμβάνει την κυκλοφορία των χαμηλής πυκνότητας λιποπρωτεϊνών-LDLs (ένας κύριος φορέας της χοληστερόλης) εντός της κυκλοφορίας του αίματος. Η χαμηλής πυκνότητας πρωτεΐνες συσσωρεύονται στο αρτηριακό τοίχωμα των μεγάλων και μεσαίου μεγέθους αρτηριών και σχηματίζουν πλάκες ή αθηρωματικά μπαλώματα, τα οποία σταδιακά προκαλούν στένωση του αυλού και έπειτα δημιουργείται αιμορραγία στη περιοχή, με αποτέλεσμα το σχηματισμό θρόμβων. Είναι γνωστό ότι οι αθηροσκληρωτικές βλάβες στο αρτηριακό τοίχωμα αναπτύσσονται σε συγκεκριμένες περιοχές στο ανθρώπινο αρτηριακό σύστημα, όπως κατά μήκος των εσωτερικών τοιχωμάτων των καμπυλωτών τμημάτων και των εξωτερικών τοιχωμάτων των αρτηριακών διακλαδώσεων. Αυτό το φαινόμενο ονομάζεται localization of atherosclerosis. Καθώς το πρώιμο συμβάν που οδηγεί στη γένεση της αθηροσκλήρωσης είναι η συσσώρευση των αθηρογόνων λιπιδίων όπως είναι οι λιποπρωτεΐνες χαμηλής πυκνότητας (LDLs) εντός του αρτηριακού τοιχώματος, η μεταφορά μάζας μεταξύ του αίματος και του τοιχώματος της αρτηρίας μάλλον διαδραματίζει σημαντικό ρόλο στην γένεση και την ανάπτυξη της αθηροσκλήρωσης . Στην παρούσα μελέτη διερευνάται η συσχέτιση της κατανομής της συγκέντρωσης των LDL (cw) στην επιφάνεια του αυλού με την κατανομή των διατμητικών τάσεων (WSS), καθώς και η επίδραση της μη - Νευτώνειας συμπεριφοράς και της παλμικής ροής του αίματος στις κατανομές της συγκέντρωσης των LDL στην επιφάνεια του αυλού κατά μήκος του τοιχώματος της ανθρώπινης αορτής. Η εξάρτηση του ιξώδους, της διάχυσης και της τοπικής πυκνότητας ενσωματώνονται στο μονοφασικό και το διφασικό μοντέλο ροής, καθιστώντας αυτές τις ποσότητες να εξαρτώνται από τη θέση. Στη συνέχεια, συγκρίνουμε τα αποτελέσματα του μονοφασικού μοντέλου με το διφασικό μοντέλο, τόσο υπό σταθερή ροή όσο και υπό ρεαλιστικές συνθήκες παλμικής ροής, χρησιμοποιώντας ένα ανθρώπινο μοντέλο αορτής κατασκευασμένο από CT εικόνες. Τέλος, μελετάτε η τοπική αιμοδυναμική με τη χρήση υπολογιστικής ρευστοδυναμικής (CFD) που εφαρμόζεται στο ρεαλιστικό γεωμετρικό μοντέλο της αορτής. Επομένως, είναι σημαντικό να λύσουμε το πρόβλημα της ακρίβειας στην ανακατασκευή του γεωμετρικού μοντέλου από την εικόνα CT, προκειμένου να έχουμε ακρίβεια στους CFD υπολογισμούς και στα αποτελέσματα. Η παρούσα αριθμητική μελέτη έδειξε ένα αντίστροφο συσχετισμό μεταξύ της διατμητικής τάσης του τοιχώματος και της συγκέντρωσης των LDL στην επιφάνεια του αυλού στην αορτή. Τα αποτελέσματα, επίσης έδειξαν ότι η συγκέντρωση των LDL στην επιφάνεια του αυλού εξαρτάται όχι μόνο από την τοπική διατμητική τάση του τοιχώματος αλλά από τα ολικά και τοπικά πρότυπα ροής. Επίσης, τα αποτελέσματα έδειξαν ότι κάτω από συνθήκες σταθερής ροής, η μη - Νευτώνεια φύση του αίματος αυξάνει τη διατμητική τάση του τοιχώματος (WSS) στις περισσότερες περιοχές της αορτής, ιδιαίτερα στις περιοχές με χαμηλή διατμητική τάση και έχει μικρή επίδραση στη συγκέντρωση των LDL (cw) στην επιφάνεια του αυλού, στις περισσότερες περιοχές της αορτής. Παρ 'όλα αυτά, μπορεί να ενισχύσει σημαντικά το cw στις περιοχές με υψηλή συγκέντρωση των LDL στην επιφάνεια του αυλού μέσω της εξαρτώμενης διατμητικής διάχυσης των LDLs. Η παλμικότητα της ροή του αίματος μπορεί να μειώσει σημαντικά το cw σε αυτές τις διαταραγμένες θέσεις. Εν κατακλείδι, η μη - Νευτώνεια συμπεριφορά του αίματος έχει μικρή επίδραση στη μεταφορά των LDL στις περισσότερες περιοχές της αορτής, αλλά στις αθηρογόνες - επιρρεπείς περιοχές όπου η συγκέντρωση LDL στην επιφάνεια του αυλού είναι υψηλή τα αποτελέσματα είναι εμφανή. Παρόμοια είναι η επίδραση της παλμικής ροής στη μεταφορά των LDLs.

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