Aortic aneurysm and dissections are potentially life threatening conditions. The advent of endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) has reduced perioperative mortality and morbidity and are now established therapy methods for treatment of aortic disease. Adequate pre- and intraoperative imaging is important for optimal results in endovascular procedures. However, the standard use of CT and angiography may not always be sufficient to provide necessary information required for treatment, and complementary techniques are warranted in selected cases. TEVAR in acute complicated type B aortic dissections is proven effective in several reports, but long-term clinical outcome and aortic remodelling are still not fully evaluated. Intravascular phased array imaging (IPAI) was used in patients undergoing EVAR and TEVAR for aortic aneurysm and dissection. The combined information from IPAI and fluoroscopy allowed exact positioning of the stent graft. The colour Doppler function facilitated detection of blood-flow in relevant arteries during and after the procedures, and it also facilitated control of ceased flow in excluded false lumens or aneurysms. Clinical early and long-term results after TEVAR for acute complicated type B aortic dissection were investigated in all patients treated between 1999 and 2009 at UppsalaUniversityHospital. Results were favourable regarding survival and permanent neurological complications. Long-term follow-up of aortic morphological changes in the same patient group showed overall significant reduction of aortic and false lumen diameters, and an increase of true lumen diameter. Total thrombosis of the false lumen occured more often in patients with DeBakey IIIa aortic dissection, than in IIIb. In conclusion, IPAI may be a complementary tool to traditional imaging modalities in EVAR and TEVAR in selected cases. Long-term clinical outcome is excellent with favourable aortic remodeling after TEVAR in patients with acute complicated type B aortic dissection.

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.

Nous présentons dans cette étude nos travaux concernant le recalage 3D/2D d'images de dissection aortique. Son but est de de proposer une visualisation de données médicales, qui pourra servir dans le contexte de l'assistance peropératoire durant les procédures endovasculaires.Pour effectuer cette tâche, nous avons proposé un modèle paramétrique de l'aorte, appelé enveloppe tubulaire. Il sert à exprimer la forme globale et les déformations de l'aorte, à l'aide d'un nombre minimal de paramètres.L'enveloppe tubulaire est utilisée par les algorithmes de recalage proposés dans cette étude.Notre méthode originale consiste à proposer un recalage par calcul direct de la transformation entre image 2D, i.e. sans procéssus d'optimisation, et est appelée recalage par ITD .Les descripteurs, que nous avons définis pour le cas des images d'aorte, permettent de trouver rapidement un alignement grossier des données. Nous proposons également l'extension de notre approche pour la mise en correspondance des images 3Det 2D.La chaîne complète du recalage 3D/2D, que nous présentons dans ce document, est composée de la technique ITD et de méthodes précises iconiques et hybrides. L'intégration de notre algorithme basé sur les descripteurs en tant qu'étape d'initialisation réduit le temps de calcul nécessaire et augmente l'efficacité du recalage, par rapport aux approches classiques.Nous avons testé nos méthodes avec des images médicales, issues de patients trîtés par procédures endovasculaires. Les résultats ont été vérifiés par les spécialistes cliniques et ont été jugés satisfaisants; notre chaine de recalage pourrait ainsi être exploitée dans les salles d'interventions à l'avenir. / In this study, we present our works related to 3D/2D image registrationfor aorti dissition. Its aim is to propose a visualization of medial datawhih an be used by physians during endovas ular proedures.For this purpose, we have proposed a parametrimodel of aorta, alleda Tubular Envelope. It is used to express the global shape and deformationsof the aorta, by a minimal number of parameters. The tubular envelope isused in our image registration algorithms.The registration by ITD (Image Transformation Descriptors) is our ori-ginal method of image alignment : itomputes the rigid 2D transformation between data sets diretly, without any optimization process.We provide thedefinition of this method, as well as the proposition of several descriptors' formulae, in the base of images of aorta. The technique allows us to quickly and a poarse alignment between data. We also propose the extension of theoriginal approach for the registration of 3D and 2D images.The complete chain of 3D/2D image registration techniques, proposedin this document, consists of the ITD stage, followed by an intensity basedhybrid method. The use of our 3D/2D algorithm, based on the image trans-formation descriptors as an initialization phase, reduces the computing timeand improves the efficiency of the presented approach.We have tested our registration methods for the medical images of several patients after endovasular treatment. Results have been approved by our clinical specialists and our approach.We have tested our registration methods for the medical images of several patients after endovascular treatment. Results have been approved by our clinical specialists and our approach may appear in the intervention rooms in the futur.

Materials which exhibit non-linear mechanical behaviors under large deformations are generally classified as “soft matter”. Elastomers represent an important class of soft materials which have wide commercial applications and isotropic non-linear behavior. In contrast, biological materials have anisotropic responses due to their heterogeneous and composite architectures. The underlying microstructure determines the arterial macroscopic behavior and is represented through constitutive models to describe the stress-strain relationships. Mechanical characterization and development of constitutive models that describe these non-linear and anisotropic properties are essential to our understanding of the structure-property relationships in these materials. In this study, we use two model systems to link the local microstructure to the overall macroscopic behaviors of soft matter. First, we delineate the roles of individual network topological factors in determining the overall macroscopic behavior of isotropic silicone elastomers using specimens fabricated with differential amounts of crosslinking. We performed mechanical experiments, within a theoretically motivated continuum mechanical framework, using a custom made planar biaxial testing instrument. These experiments demonstrate the contributions of physical entanglements and chemical crosslinks to the overall mechanical properties of silicone elastomers. Further, we show that the slip-link form of strain energy function is better suited to describe the material properties in the low to moderate regions of the stress-strain behavior. However, this model does not predict the stiffening response of elastomers at higher deformations, which is better captured using the Arruda-Boyce form of strain energy function. To explore the effects of individual topological factors on the overall network properties, we performed swelling experiments of silicone specimens in xylene and quantified variations in the polymer-solvent interaction parameter, χ, given by the Frenkel-Flory-Rehner (FFR) model. Further, we characterized the viscoelastic properties using dynamic mechanical analysis. Our results show that χ is not a constant, as assumed in the FFR model, but bears a linear relation to the equilibrium polymer volume fraction. To characterize the contribution of trapped entanglements to the overall mechanical behaviors, we use scaling laws in polymer physics and investigate the dependence of equilibrium volume fraction and experimentally obtained elastic moduli. Further, dynamic mechanical analysis demonstrated an increase in complex modulus with increase in the cross linking density. Finally, we examined variations in the uniaxial and the dynamical mechanical properties of silicone elastomers with storage time. Our results show that the time dependent increase in the modulus correlated with the formation of slip-links in the samples aged for a significantly long time in air. Together, these comprehensive studies show the importance of individual network features which affect the overall macroscopic properties of elastomers. Second, we use a multilayered and composite arterial model system to explore the passive material properties of arteries due to anisotropic layouts of extracellular matrix proteins, collagen and elastin. We characterized the mechanical properties of diseased human ascending thoracic aortic dissected (TAD) tissues, obtained from consenting patients undergoing emergency surgical repair to replace the diseased region, using multiple biaxial tests. We fit these results to micro structurally motivated Holzapfel-Gasser-Ogden model which is frequently used in the arterial mechanics literature. Our results show a higher stiffness for TAD tissues as compared to control aorta, without the presence of atherosclerotic plaques or other arterial disease. To study the directional variation in the mechanical properties of TAD tissues, we compared the stiffness in circumferential longitudinal directions at high and low stress region of equibiaxial experimental data. We observed no differences in the stiffness of TAD tissues in the circumferential and longitudinal directions. Further, we do not see any directional variations in the ultimate tensile stress, maximum extensibility, and modulus calculated in the low stretch region of uniaxial stress-strain response in TAD tissues. Histological analysis of TAD tissues showed a decrease in elastin content and an increase in collagen content as compared to control tissues. Higher TAD tissue stiffness also correlated with reduced elastin content in the arterial walls. To investigate the strain rate dependence of measured mechanical properties we use high testing rates of 1mm/sec to show that the TAD tissues have higher stiffness in the circumferential direction as compared to longitudinal direction. Finally, we used peel experiments to quantify the rupture potential of aortic dissected tissues. Our results show that TAD tissues have reduced delamination strength between layers as compared to control aortic tissues. To the best of our knowledge, no previous study has reported the mechanical property of human TAD tissues and these are the only biomechanical results on TAD tissues reported in specimens from South Asian patients. We hope that such studies will be useful for researchers who rely on microstructure based constitutive models to accurately describe the mechanical environment of cells which are important in the remodeling of tissues and in numerical models to assess mechanical criteria which may lead to the growth or dissection of arterial tissues.

L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts. / The main objective of this work is to study in depth advanced biostatistical techniques in adult cardiac surgery outcome research. The studies were designed to incorporate the concepts of survival analysis, regression analysis with propensity score, and cost analysis. The first manuscript assessed survival, and cardiovascular specific mortality, following surgical repair of acute ascending aortic dissection. The statistical analyses included survival analyses with multiphase parametric hazard regression and other parametric (exponential, Weibull), semi-parametric (Cox) or non-parametric models (Kaplan Meier), comparison with the survival of a matched cohort for age, gender and race using State lifetables, and modelization with bootstrapping and multinomial logit models. The study showed that the early and late survival following surgical repair has improved progressively over 25 years in association with noticeable changes in surgical techniques and preoperative diagnostic testing. The second manuscript focused on outcomes following isolated coronary artery bypass grafting in patients with a history of percutaneous coronary intervention. The statistical analyses included multivariable regression models with propensity score, complex matching algorithm (1:3) and appropriate statistical analyses for matched groups (standardized differences, generalized estimating equations, and survival analyses with stratified proportional hazards models). The study showed that remote prior percutaneous coronary intervention more than 14 days before coronary artery bypass grafting surgery was not associated with adverse outcomes at short or long-term follow-up. The third manuscript evaluated the financial consequences and the changes in case mix that occurred at an academic medical center subsequent to the implementation of a satellite cardiac surgery program. The statistical analyses included two-way ANOVA multivariable regression models (logistic, linear or ordinal), propensity score, and cost analyses using Log-Normal parametric models. “Survival” analyses models were also explored, using “cost” instead of “time” as the outcome of interest, and led to similar conclusions. The study showed that, after implementation of the satellite cardiac surgery program, fewer patients of lower complexity came to the academic medical center from the satellite program area, with a significant increase in nursing workload and costs.

L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts. / The main objective of this work is to study in depth advanced biostatistical techniques in adult cardiac surgery outcome research. The studies were designed to incorporate the concepts of survival analysis, regression analysis with propensity score, and cost analysis. The first manuscript assessed survival, and cardiovascular specific mortality, following surgical repair of acute ascending aortic dissection. The statistical analyses included survival analyses with multiphase parametric hazard regression and other parametric (exponential, Weibull), semi-parametric (Cox) or non-parametric models (Kaplan Meier), comparison with the survival of a matched cohort for age, gender and race using State lifetables, and modelization with bootstrapping and multinomial logit models. The study showed that the early and late survival following surgical repair has improved progressively over 25 years in association with noticeable changes in surgical techniques and preoperative diagnostic testing. The second manuscript focused on outcomes following isolated coronary artery bypass grafting in patients with a history of percutaneous coronary intervention. The statistical analyses included multivariable regression models with propensity score, complex matching algorithm (1:3) and appropriate statistical analyses for matched groups (standardized differences, generalized estimating equations, and survival analyses with stratified proportional hazards models). The study showed that remote prior percutaneous coronary intervention more than 14 days before coronary artery bypass grafting surgery was not associated with adverse outcomes at short or long-term follow-up. The third manuscript evaluated the financial consequences and the changes in case mix that occurred at an academic medical center subsequent to the implementation of a satellite cardiac surgery program. The statistical analyses included two-way ANOVA multivariable regression models (logistic, linear or ordinal), propensity score, and cost analyses using Log-Normal parametric models. “Survival” analyses models were also explored, using “cost” instead of “time” as the outcome of interest, and led to similar conclusions. The study showed that, after implementation of the satellite cardiac surgery program, fewer patients of lower complexity came to the academic medical center from the satellite program area, with a significant increase in nursing workload and costs.