There is a huge unmet clinical need for a new, safe and effective minimally invasive treatment for Acute Ascending Aortic Dissection (AAAD) (1). In 2012 AAAD has a mortality rate of 1-2% per hour within the first 24 hours, and even with contemporary surgical techniques, advanced intensive and post operative care, the mortality from AAAD following surgery in most series remains in the unacceptable range of 10-30% at 30 days (2;3). 28% of patients presenting with AAAD are denied life saving surgery often because of age or co-morbidity - medical therapy alone associated with an in hospital mortality rate in excess of 50% (2;4-6). Currently available endovascular stent grafts used in the descending thoracic and abdominal aorta are not adequately designed to be utilised within the ascending aorta. They have a large stowed diameter 22-25 French (F), with a rigid covering of either Dacron or ePTFE, and a stiff inflexible delivery system unlikely to traverse the aortic arch without complication. While the contemporary results of elective surgery for ascending thoracic aortic aneurysm (ATAA) are good, with an elective mortality of <5%, surgical results for AAAD have improved little over the last 20 years, with a 30 day mortality rate between 10-30% (3;7). With the emerging role of endovascular stent grafts in the treatment of thoracic aneurysm and dissection, with shorter hospital stays and improved outcomes I believe now is the time for the development of a percutaneous solution for AAAD. Potential ascending thoracic aortic graft (ATAG) designs must take into account the very close proximity of intimal tear to both the coronary arteries and aortic valve, allowing a 4 good proximal graft seal without compromising coronary flow or aortic valve competence. ATAG should have a low profile, with a thin non porous covering and a flexible delivery sheath with accurate and precise deployment characteristics. Following a literature review and novel anatomical data collection from computerised tomography (CT) and magnetic resonance imaging (MRI) scans of AAAD and ATAA patient cohorts, it seems that 3 embodiments of ATAG should be designed and developed, all sharing advanced core technologies including a laser-cut nitinol stent frame, thin polyurethane (PU) material covering and accurate and precise deployment mechanisms: 1) The “supra-coronary tubular ATAG”, for treating AAAD with an intimal tear in the ascending aorta, no coronary or aortic valve involvement and adequate landing zones above the coronary arteries and before the right brachiocephalic trunk (RBCT). It is likely that this graft will be capable of treating at least a third of all patients with AAAD (8). 2) The “inverted t-shirt ATAG” to proactively protect coronary artery flow and achieve proximal seal within the sinuses in patients with an intimal tear in close association or involving the coronary arteries. 3) The “valved ATAG” to treat patients who have significant aortic regurgitation (AR), to achieve a proximal seal at the annulus when anatomy suggests it would be difficult to achieve with embodiment 1) or 2), and in those patients who have a hugely dilated aortic root, so that the ATAG can seal proximally at a relatively normal annulus size, and seal distally at a normal ascending aorta diameter 5 proximal to the RBCT. This could be the treatment option for the 25-35% of AAAD patients who currently require aortic valve repair or replacement (9). The most complex of the 3 devices above is embodiment 2), the “inverted t-shirt ATAG”, as it must ensure proximal aortic seal within an often dilated sinus, without compromise to aortic valve and proactively protect both coronary arteries with 2 coronary sleeves. Basic proof of concept (PoC) of this embodiment has been demonstrated in vitro within a normal sized aortic glass model, with some important study limitations, nevertheless it does demonstrate that tracking an ATAG branched graft with 2 coronary sleeves is possible over 3 guidewires and deploying accurately within the aortic root under both direct vision and fluoroscopy. Following successful PoC deployment I then specified and had manufactured a 2nd Generation ATAG (2G ATAG), with a laser-cut nitinol frame, longitudinal tie bars, and a novel thin PU graft covering material. The 2G ATAG has been shown to have adequate radial strength when compared to competitor devices, and can be stowed to 28 F for deployment. During ATAG development 2 patents have been filed, and I wrote with Professor Rothman a successful NIHR I4I grant for £743,000 to take ATAG from the current 28 F 2G device, towards the goal of an 18 F device with bench testing, in vitro flow rig and deployment analysis, and in collaboration with the Royal Veterinary College (RVC) into an animal model over the next 3 years (beyond the scope of this thesis). I hope that within this next development cycle ATAG can be iterated into a device that might be ready to embark on a first in man (FIM) trial to offer the AAAD population an effective and less invasive treatment strategy.

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.