Abdominal aortic aneurysm (AAA) is a prevalent disease in developed countries. While endovascular aneurysm repair is fairly successful, it has shortcomings. Polymeric endoluminal paving and sealing is a method that has previously been developed to treat a range of diseases. Our goal is to further develop this technique to treat AAA, a process we have named polymeric endo-aortic paving (PEAP). We hypothesize that PEAP will overcome many of the limitations associated with EVAR by providing a minimally invasive treatment which can be used on patients with complicated AAA geometries and reducing incidence of migration and endoleak. Additionally, we plan to incorporate drug delivery into PEAP to improve efficacy. The purpose of this work was to evaluate a potential graft material for PEAP and to develop a thrombus mimic which will aid in further PEAP development. Blends of polycaprolactone/polyurethane (PCL/PU) were assessed by characterizing their mechanical, thermoforming, and degradation properties. PCL/PU grafts have a similar stiffness to aortic tissue and can be thermoformed at temperatures approaching 37 degrees C. Blending PCL with PU significantly reduces PCL's degradation. An anisotropic hyperelastic strain energy function was developed for the PCL/PU blends and finite element modeling (FEM) was used to show that stress reduction on the AAA wall that can be achieved by PEAP is similar to current EVAR. Stiffness varies throughout the AAA thrombus, and thrombus mimics were developed that have similar stiffness, components, and structure to native AAA thrombus.

Abdominal aortic aneurysm (AAA) is a common disease that is life threatening when rupture occurs. The aims of this thesis were to study (I) the long-term survival after AAA repair, (II) the cost of repair with open (OR) and endovascular (EVAR) technique, (III) the effect of different statistical methods on interpretation of cost data, (IV) the prevalence of the disease among patients with suspected arterial disease referred to the vascular laboratory, and (V) the cost-effectiveness of selective high-risk screening. Analyses of data from the Swedish vascular registry (Swedvasc), local patient registries, patient records and hospital cost registries form the basis of this thesis. Short- and long-term survival after intact AAA repair improved over the past two decades, despite increasing patient age and rate of comorbidities over time. Compared to a general population adjusted for age, sex and calendar year, the relative 5-year survival was 90% among those surviving repair. While short-term survival improved over time after ruptured repair, relative long-term survival was stable. Despite differences in patient selection and cost structure, the total cost of AAA repair with EVAR and OR was similar in a population based setting (€28,193). There was lack of consistency in the methods used in cost-analysis in the current literature, and p-values were highly dependent on test method. The practice of selective (non-population-based) screening for AAA among patients referred to the vascular laboratory was studied. The prevalence of AAA was 4.2% among male and 1.5% among female patients. AAA was associated with high age and prevalence of arterial stenosis. Of AAAs detected through selective screening, 21.5% had undergone elective repair at 7.5 years follow-up. In a health-economic evaluation, the incremental cost-effectiveness ratio of selective screening was €11,084 per life year gained. In conclusion, survival after intact AAA repair has improved over time, despite changes in case-mix. Results of health economic reports on cost of AAA repair can be highly dependent on patient selection as well as presentation of data and the statistical methods used. Selective screening for AAA among patients referred to the vascular laboratory is cost-effective.

Objectives: Clinical implementation of 3D ultrasound (3D-US) in vascular surgery is in its infancy. The aim of this thesis was to develop novel clinical applications for 3D-US in the diagnosis and management of abdominal aortic aneurysm (AAA). Methods: Four principle clinical applications were investigated. 1) Intraoperative imaging – The ability of 3D-US to detect and classify endoleaks was compared with digital subtraction angiography in patients undergoing EVAR. 2) Detection and classification of endoleaks following endovascular aneurysm repair (EVAR) – The abilityof 3D-US to accurately detect and classify endoleaks following EVAR was compared to CTA and the final multi-disciplinary team decision. 3) AAA volume measurement – measurements using magnetic and optically-tracked 3D-US were compared to CTA. 4) Biomechanical analysis – the challenges of using 3D-US to generate surface models for biomechanical simulation was explored by development of an interactive segmentation technique and comparison of paired CT and 3D-US datasets. Optimal results were used in finite element analysis (FEA) and computational fluid dynamic(CFD) simulations. Results: 3D-US out-performed uniplanar angiography for the detection of endoleaks during EVAR. This approach allowed contrast-free EVAR to be performed in patients with poor renal function. 3D contrast-enhanced ultrasound was superior to CTA for endoleak detection and classification when compared with the final decision of the multi-disciplinary team. Optimal results for AAA volume measurements were gained using an optically tracked 3D-US system in EVAR surveillance. However, there remained a significant mean difference of 13.6ml between CT and 3D-US. Complete technical success of generating geometries for use in biomechanical analysis using 3D-US was only 5%. When the optimal results were used, a comparable CFD analysis under the conditions of steady, laminar and Newtonian flow was achieved. Using basic modelling assumptions in FEA, peak von Mises and principle wall stress was found to be at the same anatomical location on both the CT and 3D-US models but the 3D-US model overestimated the wall stress values by 41% and 51% respectively. Conclusions: 3D-US could be clinically implemented for intra-operative imaging and EVAR surveillance in specific cases. 3D-US volume measurement is feasible but future work should aim to improve accuracy and inter-observer reliability. Although the results of biomechanical analysis using the optimal results was encouraging and provided a proof-of-principal, there are a number of technical developments required to make this approach feasible in a larger number of patients.

Crossing of stent graft limbs during endovascular aneurysm repair (EVAR) is often used to assist cannulation and prevent graft kinking when the aortic bifurcation is widely splayed. Little has been reported about the implications of cross-limb EVAR, especially in comparison to conventional EVAR. Using computational fluid dynamics, this work numerically examines the hemodynamic differences between these two out-of-plane stent graft configurations against a planar configuration commonly found in literature. Predicted values of displacement force, wall shear stress, and oscillatory shear index were similar between the out-of-plane configurations. The planar configuration predicted similar wall shear stress values, but significantly lower displacement forces than the out-of-plane configurations. These results suggest that the hemodynamic safety of cross-limb EVAR is comparable to conventional EVAR. However, a study of clinical outcomes may reveal reduced thrombosis incidence and long-term structural implications for the stent graft in cross-limb EVAR.

Crossing of stent graft limbs during endovascular aneurysm repair (EVAR) is often used to assist cannulation and prevent graft kinking when the aortic bifurcation is widely splayed. Little has been reported about the implications of cross-limb EVAR, especially in comparison to conventional EVAR. Using computational fluid dynamics, this work numerically examines the hemodynamic differences between these two out-of-plane stent graft configurations against a planar configuration commonly found in literature. Predicted values of displacement force, wall shear stress, and oscillatory shear index were similar between the out-of-plane configurations. The planar configuration predicted similar wall shear stress values, but significantly lower displacement forces than the out-of-plane configurations. These results suggest that the hemodynamic safety of cross-limb EVAR is comparable to conventional EVAR. However, a study of clinical outcomes may reveal reduced thrombosis incidence and long-term structural implications for the stent graft in cross-limb EVAR.