{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T00:04:48Z","timestamp":1780445088716,"version":"3.54.1"},"reference-count":46,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,8,31]],"date-time":"2023-08-31T00:00:00Z","timestamp":1693440000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"Introduction<\/jats:title>Current abdominal aortic aneurysm (AAA) assessment relies on analysis of AAA diameter and growth rate. However, evidence demonstrates that AAA pathology varies among patients and morphometric analysis alone is insufficient to precisely predict individual rupture risk. Biomechanical parameters, such as pressure-normalized AAA principal wall strain (\u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP, %\/mmHg), can provide useful information for AAA assessment. Therefore, this study utilized a previously validated ultrasound elastography (USE) technique to correlate \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP with the current AAA assessment methods of maximal diameter and growth rate.<\/jats:p><\/jats:sec>Methods<\/jats:title>Our USE algorithm utilizes a finite element mesh, overlaid a 2D cross-sectional view of the user-defined AAA wall, at the location of maximum diameter, to track two-dimensional, frame-to-frame displacements over a full cardiac cycle, using a custom image registration algorithm to produce \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP. This metric was compared between patients with healthy aortas and AAAs (\u22653\u2005cm) and compared between small and large AAAs (\u22655\u2005cm). AAAs were then separated into terciles based on \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP values to further assess differences in our metric across maximal diameter and prospective growth rate. Non-parametric tests of hypotheses were used to assess statistical significance as appropriate.<\/jats:p><\/jats:sec>Results<\/jats:title>USE analysis was conducted on 129 patients, 16 healthy aortas and 113 AAAs, of which 86 were classified as small AAAs and 27 as large. Non-aneurysmal aortas showed higher \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP compared to AAAs (0.044\u2009\u00b1\u20090.015 vs. 0.034\u2009\u00b1\u20090.017%\/mmHg, p<\/jats:italic>\u2009=\u20090.01) indicating AAA walls to be stiffer. Small and large AAAs showed no difference in \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP. When divided into terciles based on \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP cutoffs of 0.0251 and 0.038%\/mmHg, there was no difference in AAA diameter. There was a statistically significant difference in prospective growth rate between the intermediate tercile and the outer two terciles (1.46\u2009\u00b1\u20092.48 vs. 3.59\u2009\u00b1\u20093.83 vs. 1.78\u2009\u00b1\u20091.64\u2005mm\/yr, p<\/jats:italic>\u2009=\u20090.014).<\/jats:p><\/jats:sec>Discussion<\/jats:title>There was no correlation between AAA diameter and \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP, indicating biomechanical markers of AAA pathology are likely independent of diameter. AAAs in the intermediate tercile of \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP values were found to have nearly double the growth rates than the highest or lowest tercile, indicating an intermediate range of \u03b5<\/mml:mi><\/mml:mrow>\u03c1<\/mml:mi><\/mml:mrow>+<\/mml:mo><\/mml:mrow><\/mml:msub>\u00af<\/mml:mo><\/mml:mover><\/mml:math><\/jats:inline-formula>\/PP values for which patients are at risk for increased AAA expansion, likely necessitating more frequent imaging follow-up.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fcvm.2023.1232844","type":"journal-article","created":{"date-parts":[[2023,8,31]],"date-time":"2023-08-31T09:39:38Z","timestamp":1693474778000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":11,"title":["Intermediate pressure-normalized principal wall strain values are associated with increased abdominal aortic aneurysmal growth rates"],"prefix":"10.3389","volume":"10","author":[{"given":"Zachary R.","family":"Zottola","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel S.","family":"Kong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ankit N.","family":"Medhekar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lauren E.","family":"Frye","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scarlett B.","family":"Hao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dakota W.","family":"Gonring","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adnan A.","family":"Hirad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael C.","family":"Stoner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael S.","family":"Richards","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doran S.","family":"Mix","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2023,8,31]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1016\/j.jvs.2020.03.046","article-title":"Evaluating the prevalence of abdominal aortic aneurysms in the United States through a national screening database","volume":"73","author":"Summers","year":"2021","journal-title":"J Vasc Surg"},{"key":"B2","doi-asserted-by":"publisher","first-page":"539","DOI":"10.1016\/j.jvs.2010.05.090","article-title":"Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals","volume":"52","author":"Kent","year":"2010","journal-title":"J Vasc Surg"},{"key":"B3","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1053\/j.semvascsurg.2021.02.004","article-title":"Epidemiology of abdominal aortic aneurysms","volume":"34","author":"Marcaccio","year":"2021","journal-title":"Semin Vasc Surg"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1895","DOI":"10.1056\/NEJMcp012641","article-title":"Clinical practice. Small abdominal aortic aneurysms","volume":"348","author":"Powell","year":"2003","journal-title":"N Engl J Med"},{"key":"B5","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1016\/j.jvs.2017.10.044","article-title":"The society for vascular surgery practice guidelines on the care of patients with an abdominal aortic aneurysm","volume":"67","author":"Chaikof","year":"2018","journal-title":"J Vasc Surg"},{"key":"B6","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1016\/j.ejvs.2018.09.020","article-title":"Editor\u2019s choice - European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms","volume":"57","author":"Wanhainen","year":"2019","journal-title":"Eur J Vasc Endovasc Surg"},{"key":"B7","doi-asserted-by":"publisher","first-page":"e463","DOI":"10.1161\/CIRCULATIONAHA.106.174526","article-title":"ACC\/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American association for vascular surgery\/society for vascular surgery, society for cardiovascular angiography and interventions, society for vascular medicine and biology, society of interventional radiology, and the ACC\/AHA task force on practice guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease): endorsed by the American association of cardiovascular and pulmonary rehabilitation; national heart, lung, and blood institute; society for vascular nursing; TransAtlantic inter-society consensus; and vascular disease foundation","volume":"113","author":"Hirsch","year":"2006","journal-title":"Circulation"},{"key":"B8","doi-asserted-by":"publisher","first-page":"280","DOI":"10.1067\/mva.2003.119","article-title":"The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate","volume":"37","author":"Brown","year":"2003","journal-title":"J Vasc Surg"},{"key":"B9","doi-asserted-by":"publisher","first-page":"2968","DOI":"10.1001\/jama.287.22.2968","article-title":"Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair","volume":"287","author":"Lederle","year":"2002","journal-title":"JAMA"},{"key":"B10","doi-asserted-by":"publisher","first-page":"1429","DOI":"10.1016\/j.jvs.2015.07.079","article-title":"Reconsidering gender relative to risk of rupture in the contemporary management of abdominal aortic aneurysms","volume":"62","author":"Skibba","year":"2015","journal-title":"J Vasc Surg"},{"key":"B11","first-page":"II161","article-title":"Autopsy study of unoperated abdominal aortic aneurysms. The case for early resection","volume":"56","author":"Darling","year":"1977","journal-title":"Circulation"},{"key":"B12","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1097\/00000658-199909000-00002","article-title":"Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK small aneurysm trial participants","volume":"230","author":"Brown","year":"1999","journal-title":"Ann Surg"},{"key":"B13","doi-asserted-by":"publisher","first-page":"1887","DOI":"10.1016\/j.jbiomech.2006.09.003","article-title":"Biomechanics of abdominal aortic aneurysm","volume":"40","author":"Vorp","year":"2007","journal-title":"J Biomech"},{"key":"B14","doi-asserted-by":"publisher","first-page":"589","DOI":"10.1067\/mva.2002.125478","article-title":"In vivo analysis of mechanical wall stress and abdominal aortic aneurysm rupture risk","volume":"36","author":"Fillinger","year":"2002","journal-title":"J Vasc Surg"},{"key":"B15","doi-asserted-by":"publisher","first-page":"632","DOI":"10.1016\/S0741-5214(98)70227-7","article-title":"Mechanical wall stress in abdominal aortic aneurysm: influence of diameter and asymmetry","volume":"27","author":"Vorp","year":"1998","journal-title":"J Vasc Surg"},{"key":"B16","doi-asserted-by":"publisher","first-page":"475","DOI":"10.1016\/S0021-9290(99)00201-8","article-title":"Toward a biomechanical tool to evaluate rupture potential of abdominal aortic aneurysm: identification of a finite strain constitutive model and evaluation of its applicability","volume":"33","author":"Raghavan","year":"2000","journal-title":"J Biomech"},{"key":"B17","doi-asserted-by":"publisher","first-page":"724","DOI":"10.1067\/mva.2003.213","article-title":"Prediction of rupture risk in abdominal aortic aneurysm during observation: wall stress versus diameter","volume":"37","author":"Fillinger","year":"2003","journal-title":"J Vasc Surg"},{"key":"B18","doi-asserted-by":"publisher","first-page":"494","DOI":"10.1583\/04-1239.1","article-title":"Heterogeneity of tensile strength and matrix metalloproteinase activity in the wall of abdominal aortic aneurysms","volume":"11","author":"Vallabhaneni","year":"2004","journal-title":"J Endovasc Ther"},{"key":"B19","doi-asserted-by":"publisher","first-page":"570","DOI":"10.1016\/j.jvs.2005.10.072","article-title":"Biomechanical properties of ruptured versus electively repaired abdominal aortic aneurysm wall tissue","volume":"43","author":"Di Martino","year":"2006","journal-title":"J Vasc Surg"},{"key":"B20","doi-asserted-by":"publisher","first-page":"472","DOI":"10.1016\/S1078-5884(98)80105-6","article-title":"Relationship between abdominal aortic aneurysm wall compliance and clinical outcome: a preliminary analysis","volume":"15","author":"Wilson","year":"1998","journal-title":"Eur J Vasc Endovasc Surg"},{"key":"B21","doi-asserted-by":"publisher","first-page":"112","DOI":"10.1067\/mva.2003.40","article-title":"The relationship between aortic wall distensibility and rupture of infrarenal abdominal aortic aneurysm","volume":"37","author":"Wilson","year":"2003","journal-title":"J Vasc Surg"},{"key":"B22","doi-asserted-by":"publisher","first-page":"941","DOI":"10.1111\/j.1540-8175.2008.00725.x","article-title":"A novel approach to assess aortic stiffness related to changes in aging using a two-dimensional strain imaging","volume":"25","author":"Oishi","year":"2008","journal-title":"Echocardiography"},{"key":"B23","doi-asserted-by":"publisher","first-page":"1664","DOI":"10.1016\/j.athoracsur.2013.06.037","article-title":"Method for aortic wall strain measurement with three-dimensional ultrasound speckle tracking and fitted finite element analysis","volume":"96","author":"Karatolios","year":"2013","journal-title":"Ann Thorac Surg"},{"key":"B24","doi-asserted-by":"publisher","first-page":"1737","DOI":"10.1002\/jum.16193","article-title":"Changes in aortic diameter and wall strain in progressing abdominal aortic aneurysms","volume":"42","author":"Derwich","year":"2023","journal-title":"J Ultrasound Med"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1115\/1.4043075","article-title":"Strain mapping from four-dimensional ultrasound reveals complex remodeling in dissecting murine abdominal aortic aneurysms","volume":"141","author":"Cebull","year":"2019","journal-title":"J Biomech Eng"},{"key":"B26","doi-asserted-by":"publisher","first-page":"2275","DOI":"10.1002\/zamm.201700353","article-title":"Towards non-invasive in vivo characterization of the pathophysiological state and mechanical wall strength of the individual human AAA wall based on 4D ultrasound measurements","volume":"98","author":"Wittek","year":"2018","journal-title":"Z Angew Math Mech"},{"key":"B27","doi-asserted-by":"publisher","first-page":"2372","DOI":"10.1016\/j.ultrasmedbio.2017.06.002","article-title":"Detecting regional stiffness changes in aortic aneurysmal geometries using pressure-normalized strain","volume":"43","author":"Mix","year":"2017","journal-title":"Ultrasound Med Biol"},{"key":"B28","doi-asserted-by":"publisher","first-page":"762","DOI":"10.1016\/j.jvscit.2022.09.003","article-title":"Changes in intraoperative aortic strain as detected by ultrasound elastography in patients following abdominal endovascular aneurysm repair","volume":"8","author":"Zottola","year":"2022","journal-title":"J Vasc Surg Cases Innov Tech"},{"key":"B29","doi-asserted-by":"publisher","first-page":"515","DOI":"10.1016\/j.ultrasmedbio.2012.09.023","article-title":"Non-rigid image registration based strain estimator for intravascular ultrasound elastography","volume":"39","author":"Richards","year":"2013","journal-title":"Ultrasound Med Biol"},{"key":"B30","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1016\/j.jbiomech.2015.11.008","article-title":"Ultrasound strain mapping of achilles tendon compressive strain patterns during dorsiflexion","volume":"49","author":"Chimenti","year":"2016","journal-title":"J Biomech"},{"key":"B31","doi-asserted-by":"publisher","first-page":"928","DOI":"10.1016\/j.jvs.2008.01.006","article-title":"Impact of calcification and intraluminal thrombus on the computed wall stresses of abdominal aortic aneurysm","volume":"47","author":"Li","year":"2008","journal-title":"J Vasc Surg"},{"key":"B32","doi-asserted-by":"publisher","first-page":"420","DOI":"10.1037\/0033-2909.86.2.420","article-title":"Intraclass correlations: uses in assessing rater reliability","volume":"86","author":"Shrout","year":"1979","journal-title":"Psychol Bull"},{"key":"B33","doi-asserted-by":"publisher","first-page":"141","DOI":"10.11613\/BM.2015.015","article-title":"Understanding bland altman analysis","volume":"25","author":"Giavarina","year":"2015","journal-title":"Biochem Med"},{"key":"B34","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1177\/1536867X1501500117","article-title":"Nonparametric pairwise multiple comparisons in independent groups using dunn\u2019s test","volume":"15","author":"Dinno","year":"2015","journal-title":"Stata J"},{"key":"B35","doi-asserted-by":"publisher","first-page":"1324","DOI":"10.1016\/j.jbiomech.2005.03.003","article-title":"The effects of aneurysm on the biaxial mechanical behavior of human abdominal aorta","volume":"39","author":"Geest","year":"2006","journal-title":"J Biomech"},{"key":"B36","doi-asserted-by":"publisher","first-page":"797","DOI":"10.1016\/S0741-5214(94)70004-4","article-title":"Abdominal aortic aneurysms are associated with altered matrix proteins of the nonaneurysmal aortic segments","volume":"19","author":"Baxter","year":"1994","journal-title":"J Vasc Surg"},{"key":"B37","doi-asserted-by":"publisher","first-page":"633","DOI":"10.1016\/S0950-821X(05)80708-X","article-title":"Modifications of the extracellular matrix of aneurysmal abdominal aortas as a function of their size","volume":"7","author":"Sakalihasan","year":"1993","journal-title":"Eur J Vasc Surg"},{"key":"B38","doi-asserted-by":"publisher","first-page":"149","DOI":"10.1016\/j.actbio.2019.01.070","article-title":"The role of tissue remodeling in mechanics and pathogenesis of abdominal aortic aneurysms","volume":"88","author":"Niestrawska","year":"2019","journal-title":"Acta Biomater"},{"key":"B39","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1093\/ehjci\/jey051","article-title":"Quantification of aortic stiffness and wall stress in healthy volunteers and abdominal aortic aneurysm patients using time-resolved 3D ultrasound: a comparison study","volume":"20","author":"van Disseldorp","year":"2019","journal-title":"Eur Heart J Cardiovasc Imaging"},{"key":"B40","doi-asserted-by":"publisher","first-page":"966","DOI":"10.1016\/j.jvs.2016.03.426","article-title":"Quantification of abdominal aortic aneurysm stiffness using magnetic resonance elastography and its comparison to aneurysm diameter","volume":"64","author":"Kolipaka","year":"2016","journal-title":"J Vasc Surg"},{"key":"B41","doi-asserted-by":"publisher","first-page":"208","DOI":"10.1016\/S0967-2109(98)00041-6","article-title":"The relationship between abdominal aortic aneurysm wall compliance, maximum diameter and growth rate","volume":"7","author":"Wilson","year":"1999","journal-title":"Cardiovasc Surg"},{"key":"B42","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1016\/j.jvs.2005.03.037","article-title":"Compliance of abdominal aortic aneurysms evaluated by tissue Doppler imaging: correlation with aneurysm size","volume":"42","author":"Long","year":"2005","journal-title":"J Vasc Surg"},{"key":"B43","doi-asserted-by":"publisher","first-page":"721","DOI":"10.1148\/radiol.212323","article-title":"MR elastography of abdominal aortic aneurysms: relationship to aneurysm events","volume":"304","author":"Dong","year":"2022","journal-title":"Radiology"},{"key":"B44","doi-asserted-by":"publisher","first-page":"187","DOI":"10.1016\/j.avsg.2021.05.051","article-title":"The short-term predictive value of vessel wall stiffness on abdominal aortic aneurysm growth","volume":"77","author":"Lorenzen","year":"2021","journal-title":"Ann Vasc Surg"},{"key":"B45","doi-asserted-by":"publisher","first-page":"502","DOI":"10.1111\/opo.12131","article-title":"When to use the bonferroni correction","volume":"34","author":"Armstrong","year":"2014","journal-title":"Ophthalmic Physiol Opt"},{"key":"B46","doi-asserted-by":"publisher","first-page":"1644","DOI":"10.1016\/j.athoracsur.2015.11.024","article-title":"Adjust for multiple comparisons? It\u2019s not that simple","volume":"101","author":"Althouse","year":"2016","journal-title":"Ann Thorac Surg"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2023.1232844\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,8,31]],"date-time":"2023-08-31T09:39:40Z","timestamp":1693474780000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2023.1232844\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,8,31]]},"references-count":46,"alternative-id":["10.3389\/fcvm.2023.1232844"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2023.1232844","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,8,31]]},"article-number":"1232844"}}