Pulsatile Flow Leads to Intimal Flap Motion and Flow Reversal in an In Vitro Model of Type B Aortic Dissection

Understanding of the hemodynamics of Type B aortic dissection may improve outcomes by informing upon patient selection, device design, and deployment strategies. This project characterized changes to aortic hemodynamics as the result of dissection. We hypothesized that dissection would lead to elevated flow reversal and disrupted pulsatile flow patterns in the aorta that can be detected and quantified by non-invasive magnetic resonance imaging. Flexible, anatomic models of both normal aorta and dissected aorta, with a mobile intimal flap containing entry and exit tears, were perfused with a physiologic pulsatile waveform. Four-dimensional phase contrast magnetic resonance (4D PCMR) imaging was used to measure the hemodynamics. These images were processed to quantify pulsatile fluid velocities, flow rate, and flow reversal. Four-dimensional flow imaging in the dissected aorta revealed pockets of reverse flow and vortices primarily in the false lumen. The dissected aorta exhibited significantly greater flow reversal in the proximal-to-mid dissection as compared to normal (21.1 +/- 3.8 vs. 1.98 +/- 0.4%, p < 0.001). Pulsatility induced unsteady vortices and a pumping motion of the distal intimal flap corresponding to flow reversal. Summed true and false lumen flow rates in dissected models (4.0 +/- 2.0 L/min) equaled normal flow rates (3.8 +/- 0.1 L/min, p > 0.05), validated against external flow measurement. Pulsatile aortic hemodynamics in the presence of an anatomic, elastic dissection differed significantly from those of both steady flow through a dissection and pulsatile flow through a normal aorta. New hemodynamic features including flow reversal, large exit tear vortices, and pumping action of the mobile intimal flap, were observed. False lumen flow reversal would possess a time-averaged velocity close to stagnation, which may induce future thrombosis. Focal vortices may identify the location of tears that could be covered with a stent-graft. Future correlation of hemodynamics with outcomes may indicate which patients require earlier intervention.