EFFECTS OF INTRALUMINAL THROMBUS

AND WALL THICKNESS

ON WALL STRESS OF HYPOTHETICAL
SYMMETRIC AND ASYMMETRIC
ABDOMINAL AORTIC ANEURYSM

Juvy A. Balbarona
Department of Mechanical Engineering
University of the Philippines-Diliman
Quezon City, Philippines

Abstract

Abdominal aortic aneurysm (AAA) is a focal ballooning of the terminal aortic segment
that is caused by a weakened area in the main vessel that supplies blood from the heart to the
rest of the body. It occurs gradually over a span of years and is considered a health risk as it
may rupture if not treated. Current AAA repair are expensive and because they are not without
complications, the clinician is faced with a decision whether the risk of rupture outweighs the
risk associated with repair. The current criterion for elective repair is an aneurysmal maximum
diameter of 5.5 cm but a considerable number of cases have shown that this is an unreliable
predictor of rupture.
From a biomechanical point of view, the best predictor for rupture is when the wall
stress exceeds the ultimate strength of local wall tissue. A clear knowledge of the biomechanical
behavior of AAA tissue may therefore prove very important in understanding the underlying
mechanisms behind the changes involved with AAA formation and may improve the prediction of
the occurrence of rupture. The purpose of this work is to obtain qualitative information on how
intraluminal thrombus and asymmetry influence aneurysm wall stress. Four sets of three
dimensional hypothetically modeled AAA are the subject of this study. A published hyperelastic
strain energy function is used as the material model for the AAA wall. Using finite element
method, the stress distribution on the aortic wall under systolic pressure is determined for all 16
AAA models.
Results showed the distribution of wall stresses, with peak wall stresses located at the
inner wall of the AAA, for both axially symmetric and asymmetric models. The stress gradient
through the AAA wall shows that the wall strength distribution within any particular AAA is
spatially variable. The effect of increasing the aneurismal wall thickness and the incorporation
of intraluminal thrombus and also its increased thickness showed profound influence on the
magnitude and distribution of stresses on AAA wall.
1. INTRODUCTION

Abdominal aortic aneurysms (AAAs) are irreversible enlargements of the largest artery in

the human body affecting 0.4% of people over the age of 50 [2]. By convention, an infrarenal

aorta 3 cm in diameter or larger is considered aneurismal and if left untreated, may expand over a

period of time. Abdominal aortic aneurysm is a health risk because of the fatality associated with

the continuing expansion of the abdominal aorta and its ultimate rupture once the induced

mechanical wall stress exceeds the local minimum strength of the AAA wall [2]. An estimated

13,000 patients die each year from AAA rupture in the US alone [5]. While AAA rupture may

occur without significant warning, its risk assessment is, at present, generally based on critical

values of the maximum AAA diameter (>5 cm) and AAA-growth rate (>0.5 cm/year) [10].

These criteria, however, may be insufficient for reliable AAA-rupture risk assessment especially

when predicting possible rupture of smaller AAAs.

Autopsy studies have shown that AAAs that are considered small can rupture, while

some of those considered large will not rupture, given the life expectancy of the patient. Darling

et al [6] studied records from 24,000 consecutive, non-specific autopsies performed over a 23-

year period and found that nearly 13% of AAA 5 cm in diameter or smaller ruptured, and 60% of

the aneurysms greater than 5 cm in diameter never ruptured. Similarly, Hall et al [12]

summarized a group of studies indicating that up to 23% of AAA ruptured at a diameter < 5 cm.

The discrepancies between these studies suggest that the maximum diameter criterion is not

enough to reliably evaluate the susceptibility of a particular AAA to rupture. Many refer to the

Laplace Law as the basis for the “maximum diameter criterion” for predicting the potential

rupture of AAA. This law states that the stress in the AAA wall is proportional to its diameter.

However, the use of the Law of Laplace to predict AAA rupture potential is erroneous in that

AAA wall geometry is not a simple cylinder or sphere with a single radius of curvature, for

2
which the Law of Laplace is valid. Rather, the AAA wall is complexly shaped with both major

and minor wall curvatures. For example, it has been shown by various studies (Vorp et al,

Raghavan et al, Wang et al, and others) [6] that the stresses acting on an AAA are not evenly

distributed and cannot be adequately described by the Law of Laplace. To use only the maximum

diameter to predict wall stresses in AA, therefore underestimates the significant contributions of

local complex wall surface shapes. Numerous other studies also suggest that consideration of

wall stress alone is not sufficient to predict AAA rupture.

The asymmetry of AAA is another important factor that needs to be considered in the

estimation of stress distribution on AAA wall. Due to the local support provided by lumbar

vertebrates, most abdominal aortic aneurysms are asymmetric. Generally, the anterior size is

greater than the posterior size with a larger wall thickness at the posterior side than at the anterior

side. Various studies have proven that a simple axis-symmetric model is unreliable in predicting

the location and magnitude of maximum stresses in most AAAs since both AAA surface

geometry and hence stress distributions are highly complex. Scotti et al [14] conducted a study

based on fluid-structure interaction analysis and reported that an asymmetric AAA with non-

uniform wall thickness would be subjected to higher mechanical stresses and an increased risk of

rupture compared to a more fusiform AAA with uniform wall thickness. Thus, assessing rupture

risk for typical AAAs may require detailed three-dimensional modeling to include the effects of

both wall thickness and geometry asymmetry on the stress exhibited by a virtual AAA.

Some investigators have also looked at the possible influence of intraluminal thrombus

(ILT) on the stresses involved in the development of AAA. Vorp et al. [6] reported that an ILT

could provide a cushioning effect by improving the compliance of the wall and reduce the

mechanical stress, hence could be beneficial for preventing AAA rupture. Mower et al [13]

simulated the ILT in an AAA and found that the maximum wall stress decreases as the size of

3
the ILT increases, and that an ILT significantly reduced AAA wall stress if the ILT became

solid. In contrast, some researchers declared that ILTs could accelerate AAA rupture. For

example, Wolf et al. [6] found that an increased AAA-ILT volume translates to a higher

likelihood of rapid expansion, and further concluded that the larger the ILT volume, the greater

is the propensity for rupture.

Stenbaek et al [7] on the other hand considers the growth of ILT as a better predictor of

rupture than AAA diameter. Some researchers however, confirm that the presence of

intraluminal thrombus does not have anything to do with the propensity of AAA to rupture.

Schurink et al [18] found that the blood pressure close to the inner wall of an AAA is almost the

same as that in the lumen, and further concluded that thrombus within the aneurysm does not

reduce the risk of rupture of the aneurysm since the pressure near the aneurismal wall is not

reduce by it.

Clearly, a great deal of research effort has been devoted to the development of tools that

will reliably predict the likelihood of AAA rupture on a patient-specific basis that will help

clinicians decide whether the risk of AAA rupture justifies the risks associated with repair.

Accurate estimation of the wall stress distribution in an abdominal aortic aneurysm (AAA) may

prove clinically useful in predicting when a particular aneurysm will rupture. Precise three-

dimensional model and appropriate constitutive description for both the wall and the intraluminal

thrombus (ILT) found in most AAA are necessary for this task. The purpose of this work is to

determine the maximum stresses and locations of these stresses on hypothetical aneurysm and

how these parameters are affected by the thickness of aneurismal wall.

Because it is difficult to directly measure the stresses in AAA, finite element analysis

using software packages are used instead. Finite element analysis is a mathematical technique

used to model stresses in complex structures, and a system such as a pressurized abdominal

4
aortic aneurysm can be modeled using an approximate function instead of an exact mathematical

model. Numerous studies have employed this technique to examine wall stress distributions and

to determine how biomechanical and geometric factors affect these stresses [13]. These studies

have shown the effect of several factors such as diameter, wall thickness, shape and material

physical properties on the stress distributions of AAA.

The effect of intraluminal thrombus on wall stress distribution is also investigated for

both symmetric and asymmetric AAA models. A secondary objective of the study is to be able to

apply hyperelasticity to AAA simulations and to explain the causes of high stress locations in an

AAA.

AAA rupture is a complicated event dependent upon the maximum diameter, expansion

rate, diastolic pressure, wall stress and strength, asymmetry, intraluminal thrombus, and stiffness

change to name a few. And because each of these factors require detailed study, this work only

covers the factors that can possibly affect the maximum stresses in loaded virtually modeled

aneurismal abdominal aorta, such as wall thickness and intraluminal thrombus.

Fig.1 Typical human abdominal aorta [14]

5
3. MATERIALS AND METHODOLOGY

3.1. Development of the 3D Model

The study is divided into four sections designed to systematically evaluate a specific

material characteristic and investigate how changes to these physical characteristics influence

aneurysm wall stress.

Using the CAD software ProEngineer Wildfire 3, aneurysms were modeled as structures

with walls constructed of homogeneous, isotropic materials that exhibit hyperelastic

deformation. A total of 16 AAA were generated with a fixed length of 120 mm and undilated

diameters of 2 cm at the outlet and inlet sections. To observe the effect of wall thickness, the four

models in the first set of analysis differ in degree of uniform wall thickness, with the initial

thickness t, being 1.5 mm and increasing by 0.2 mm up to a maximum wall thickness of 2.1 mm.

The second set of models is also with increasing degree of uniform wall thickness, but with

aortic sac that is not axis symmetric. This is to determine the effect of increasing wall thickness

on asymmetric AAA models. To determine the effect of intraluminal thrombus, the third set of

models is generated by modifying the first set by including increasing ILT thickness, with the

initial ILT thickness being 2 mm and increasing by 5mm up to a maximum of 17mm, measured

from the maximum diameter. The effect of intraluminal thrombus, this time on asymmetric AAA

models were done by generating a modification of the second set of models by also including

increasing ILT thickness that is of similar magnitude as the third set of models. The final models

were saved in IGES format for importing to ANSYS 11.

3.2. Approximation of the Constitutive Model

6
 A hyperelastic or Green elastic material, a special case of a Cauchy elastic material, is an

ideally elastic material for which the stress-strain relationship derives from a strain energy

density function. Hyperelastic materials in general have very small compressibility. Studies by

Vorp et al. [6] reported measures of AAA wall stiffness and formulated both microstructure-

based and hyperelastic, continuum-mechanics based models for the AAA wall. The hyperelastic

material model assumes that the material’s response is isotropic and isothermal. This assumption

enables the strain energy potentials to be expressed in terms of strain invariants or principal

stretch ratios. Unless otherwise stated, the materials are also assumed to be nearly or purely

incompressible. Material thermal expansion is also assumed to be isotropic. The continuum-

based AAA wall tissue model formulated by Raghavan and Vorp is a special case of the

generalized neo-Hookean model with the Cauchy stress tensor T taking the form

.
+ α 2−
T =−p +1 2[ βI( 3)]
1B

Here, p is the hydrostatic pressure within the material, 1 is the identity tensor, and B is the left

Cauchy-Green stretch tensor, B = FFT, where F is the deformation gradient within the material. I1

is the first invariant of B. The model parameters α and β represent the mechanical properties of

the AAA wall, which were determined to be α = 17.4±1.5 N/cm2 and β = 188.1±N/cm2. This

constitutive model and the mean parameter values for the aneurismal wall have found extensive

use in the computational stress analyses of individual AAA.

In this study, an approximate Mooney-Rivlin hyperelastic model was used as outlined by

Danao [8]. It was used as a substitute to the constitutive model proposed by Raghavan. The

constitutive model of Raghavan was

W =αI(−B +3)β −
I( B 3) 2

7
where IB is the first invariant of the Cauchy-green tensor, and α and β are the mean values of the

material parameters determined from their experiment. The Mooney-Rivlin hyperelastic model

used was the 5 parameter option. To get the approximate function, the following constants were

adopted

c10 =α c01 =0
c20 = β c11 =0
c02 =0 d =0

where
W = α ( I1 − 3) + β( I1 −3)2

α = 17.4 N/cm2

β= 188.1 N/cm2.

The final form reduces to the Raghavan model

.
W = α (I 1− 3)+ β (I −
1 3)
2

3.3. Simulation

The output IGES files were imported to finite element software ANSYS11. An internal

systolic pressure of 0.0160 MPa (120 mmHg) was applied to the inner wall to simulate the end

systolic conditions that represent the stage in the cardiac cycle in which the largest wall stress is

experienced by the AAA. The constraints due to the renal and iliac arteries at the proximal and

distal parts of the aneurysm were simulated by constraining the displacements at both ends to

zero.

The element type chosen was a 20-node, hyperelastic solid element. All the models were

meshed using software’s built-in meshing algorithm “SMART SIZING” with setting of “4”.

8
Tetrahedral elements were chosen and static, large displacement analyses were performed with a

minimum of 100 load sub steps. Nodal contour plots of the von Mises stress were used to

evaluate the stress state of the model.

Fig. 2. Meshed IGES file in ANSYS.

4. RESULTS AND DISCUSSION

Since an AAA is subject to a system of loads in 3 dimensions, a complex 3 dimensional

system of stresses is developed. That is, at any point within the body there are stresses acting in

different directions, and the direction and magnitude of stresses change from point to point. Even

though none of the principal stresses exceeds the yield stress of the material, it is possible for

yielding to result from the combination of stresses. The Von Mises criterion is a formula for

combining these 3 stresses into an equivalent stress, which is then compared to the yield stress of

the material. Knowing this, only the von Mises stress distributions were observed and plotted for

all the AAA models. The von Mises stress is a stress index that is a combination of nine

components and studying the von Mises stress, instead of each component, allows for

meaningful interpretation of results [8].

9
 A total of 16 simulations were performed for each model to determine the maximum

stresses for symmetric and asymmetric models. Von Mises stresses were plotted against

increasing uniform wall thickness for both axially symmetric and asymmetric AAA models

whose thickness is uniform from inlet to outlet.

Fig 3. Plot of the maximum von Mises stress for symmetric AAA models with uniform thickness.

Fig 4. Plot of the maximum von Mises stress for asymmetric AAA models with uniform thickness.

Fig 5. Plot of the maximum von Mises stress for symmetric AAA models with increasing ILT thickness.

Fig 6. Plot of the maximum von Mises stress for asymmetric AAA models with increasing ILT thickness

As can be seen from the graphs, an increase in uniform wall thickness for both symmetric

and asymmetric AAA models gives a decrease in maximum wall stress. Specifically, for

symmetric AAA models with uniform thicknesses, an increase in wall thickness by a little over

13% exhibits a decrease in peak wall stress by 13% also. But interestingly, result shows that an

increase in wall thickness from 1.9 mm to 2.1mm only contributed to 9.29% decrease in the peak

von Mises stress. This shows that increased wall thickness indicates a decrease in maximum

stress experienced by the AAA but the relationship is not necessarily linear. And this is also in

agreement with the results presented by Danao [8] in his study where a thicker AAA wall

experiences smaller peak von Mises stress.

10
 Fig. 7. Axis symmetric model with uniform thickness showing
the distribution of von Mises stresses.

For the AAA models with uniform thicknesses but with asymmetric aortic sac, an

increase in wall thickness by 13.33% yields a decrease of 10.94% in the maximum wall stress.

Further increase in wall thickness by 26.67% gives a slight decrease in the maximum wall stress

of about 6%, while a 40% increase in wall thickness contributes to only 5.33% decrease of the

peak wall stress.

Another interesting observation is the location of the peak wall stresses which,

incidentally, is also the location of maximum wall strain. For the models that are axis-symmetric

and with uniform wall thicknesses, the maximum stresses occur near the proximal and distal

ends of the aneurysm, whereas for the models that have asymmetric aortic sac but with uniform

wall thicknesses, the peak wall stresses are located at the inflection points in the posterior region.

Note that the maximum stress value appears at the inner surface of the aneurysm and that there

exists a stress gradient through the aneurysm wall thickness.

11
 Fig. 8. Model with asymmetric aortic sac with uniform
thickness showing von Mises stress distribution

Intraluminal thrombus (ILT) is also seen to reduce peak AAA wall stresses in all the

models. The plot for Von Mises stress against ILT thickness for axially symmetric models show

that increased ILT thickness from 2mm to 7mm exhibits a considerable decrease in maximum

von Mises stress by 38.75%. But further increase in the ILT thickness by 5mm results only to a

little more than 1% decrease of the maximum von Mises stress. These results corroborate those

by Mower et al where the consideration of intraluminal thrombus in their AAA models not only

produced a greater magnitude of stress reduction in larger aneurysms, but the relative decrease in

stress was greater. Perhaps incidentally, peak stresses and wall strains are located at the proximal

and distal neck of the AAA models.

For models with asymmetric aortic sac and increasing ILT thickness, significant decrease

in peak wall stress from 0.3639 MPa to 0.1554 MPa is observed when ILT thickness is increased

from 2mm to 17mm. Maximum stresses are located at the inner wall of the AAA, specifically, at

12
the inner wall of the posterior region. Surprisingly, even though the posterior region is almost

flat, peak stresses can be seen at the location corresponding to the inflection points. This result is

somewhat similar to the results obtained by Holzapfel et al where they modeled AAA using

anisotropic material model and found out that the maximum principal stress in the aneurismal

wall relocates from the midsection of the bulge to the section where the inflection in the

aneurismal surface occurs. Their results also showed that for asymmetric cases, the maximum

stress is located in the surface opposite to the aneurysm bulge.

Comparison of wall stresses between asymmetric and symmetric aortic sac showed that

asymmetric AAA experience significantly greater walls stresses. This could be explained by the

fact that symmetric aneurysms experience symmetrically balanced pressure in the

circumferential direction, whereas for asymmetric aneurysms, asymmetry in geometry cause

larger stresses along the area where the curvature of the aneurismal surface changes.

The cushioning effect of intraluminal thrombus as demonstrated by the results in this

study is also in agreement with findings by Mower et al [13] where they found that intraluminal

thrombus produced a greater magnitude of stress reduction in larger aneurysms.

13
 Fig. 9. Axis symmetric model with ILT showing the distribution
of von Mises stresses

.
Fig. 10. Model with asymmetric aortic sac with ILT showing
the distribution of von Mises stress

5. CONCLUSIONS AND RECOMMENDATIONS

While the stress analyses using 3D hypothetical AAA models are helpful for the purpose

of research, the wall stress distribution in real, in vivo AAA is even more complex. The results of

this study describe the wall stress distributions for hypothetical aneurismal models and how these

stresses are affected by changes in geometric characteristics of AAA. Peak wall stresses are

located at the inner wall of the AAA, for both axially symmetric and asymmetric models. The

stress gradient through the AAA wall shows that the wall strength distribution within any

particular AAA is spatially variable and this seems to confirm earlier studies by Thubrikar et al

[12]. The influence of aneurysm wall thickness, intraluminal thrombus, as well as asymmetry in

the distribution of stresses in AAA suggest that rupture risk prediction based on peak wall stress

is mostly dependent on local geometric parameters of the aneurysm.

14
 Further research is proposed in view of the many limitations and assumptions made while

doing this study. It is suggested that the effects of increased ILT thickness alongside the increase

in AAA inlet and outlet thicknesses be taken into consideration in future researches. Since this

study was not based on patient-specific data, constant wall thickness was used on some models

and smooth geometries were used on both symmetric and asymmetric models. This assumption

neglects the possible presence of calcification in the tissue, and should certainly be accounted for

in future computational studies. The possible effects of increased asymmetry in conjunction with

the increase in ILT thickness is also another suggestion. Another important aspect that is

recommended for future analysis is the use of anisotropic material model in approximating the

properties of intraluminal thrombus.

6. LIMITATIONS

The particular aim of this study is to obtain qualitative information on how intraluminal

thrombus and asymmetry influence aneurysm wall stress. Analysis of the detailed quantitative

behavior of patient-specific aneurysms is definitely beyond the scope of this study. To this end,

simplified, static aneurysm models were used, and this does not allow any analysis involving

pulsatile flow effects. It should be kept in mind that in reality, aneurysms are not axisymmetric,

smooth structures that are homogeneous, and isotropic, and they do not exhibit linear elastic

deformation. Furthermore, natural aneurysms exhibit wide variation in shape, size, material

properties, and loading conditions. These and the simplifying assumptions make the result of this

study quantitatively limited. Thus, it would be imprudent to use the results from this study to

predict the stresses that are actually present in individual aneurysms. However, the results

confidently assert that intraluminal thrombus will significantly reduce wall stress, and that the

15
amount of stress reduction is related to the asymmetry of the aneurysm. Future studies using

patient specific models may be useful in determining the degree of complexity appropriate for

individual aneurysm that may be helpful in making quantitative decisions for individual patients.

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[10] Li Z., Kleinstreuer C. A comparison between different asymmetric abdominal aortic
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Appendix

For all four sets of models, dmax = 5.5 cm and D = 2cm

1st Set of models with uniform thickness 2nd Set of models with ILT

max. Von Mises max. Von Mises

t (mm) Stress (Mpa) t = 1.5 t (ILT) Stress (Mpa)
AShell1 1.5 0.291336 AwILT1A 2mm 0.214211
AShell2 1.7 0.251269 AwILT1B 7mm 0.131203
AShell3 1.9 0.218215 AwILT1C 12mm 0.129778
AShell4 2.1 0.197944 AwILT1D 17mm 0.127608

18
3rd Set of Models with Asymmetric aortic sac 4th Set of Models with ILT

max. Von Mises max. Von Mises

t (mm) Stress (Mpa) t = 1.5 t (ILT) Stress (Mpa)
BShell1A 1.5 0.395681 BwILTA 2mm 0.363953
BShell1B 1.7 0.35241 BwILTB 7mm/5mm 0.275262
BShell1C 1.9 0.331263 BwILTC 12mm/5mm 0.185027
BShell1D 2.1 0.313599 BwILTD 17mm/5mm 0.155464

19