Local biaxial deformation measurements are essential for the in-depth investigation of tissue properties and remodeling of the ascending thoracic aorta, particularly in aneurysm formation. Current clinical imaging modalities pose limitations around the resolution and tracking of anatomical markers. We evaluated a new intra-operative video-based method to assess local biaxial strains of the ascending thoracic aorta. In 30 patients undergoing open-chest surgery, we obtained repeated biaxial strain measurements, at low- and high-pressure conditions. Precision was very acceptable, with coefficients of variation for biaxial strains remaining below 20%. With our four-marker arrangement, we were able to detect significant local differences in the longitudinal strain as well as in circumferential strain. Overall, the magnitude of strains we obtained (range: 0.02–0.05) was in line with previous reports using other modalities. The proposed method enables the assessment of local aortic biaxial strains and may enable new, clinically informed mechanistic studies using biomechanical modeling as well as mechanobiological profiling.

Background Dysfunctional cellular mechanosensing appears central to aneurysm formation [1]. We aimed to derive material parameters of aneurysm tissue from in vivo deformations, which may increase insight into the underlying structural integrity of the pathological tissue. Methods Videos of tracking markers (example Video in supplement, screenshot in Figure) placed on ascending aortic segments were captured alongside radial arterial blood pressure in patients undergoing open-thorax ascending thoracic aorta aneurysm (ATAA) repair (n = 5) and coronary bypass (controls; n = 2). Normalised cross-correlation was used to determine marker displacements, resulting in estimates of systolic/diastolic diameters, distensibility, and cyclic axial engineering strain. A thinwalled, cylindrical geometry was assumed, with amorphous (Neo-Hookean) and fibrous (two-family) constitutive contributions [2]. This framework was fitted to individual patient measurements, by varying parameters c (amorphous material constant), k1 and k2 (fiber stiffness and strain stiffening parameter), β (fiber angle w.r.t. circumferential direction), unloaded intact length (L), and internal radius (Ri). Results Axial strain tended to be lower (expected) and distensibility larger (unexpected) in aneurysm than controls (Figure). However, the intrinsic pressure-dependence of distensibility must be considered when drawing conclusions related to differences in structural stiffness between both groups [3]. Material stiffness parameters (c and k1) appeared higher in aneurysm patients than in controls which is in line with previous studies in mice [4]. Conclusion We are developing a method to determine ATAA material properties from in vivo deformations and observed increased material stiffness in ATAA. Aneurysm Control Measured outcomes Diastolic diameter [mm] 40 ± 5 23 ± 3 DBP [mmHg] 58 ± 11 34 ± 2 SBP [mmHg] 90 ± 18 93 ± 7 Distensibility [MPa–1] 4.3 ± 3.0 3.7 ± 1.1 Axial strain [%] 4.3 ± 2.1 7.6 ± 3.5 Estimated properties c [kPa] 37 ± 29 15 ± 13 k [kPa] 43 ± 26 24 ± 24 R1 [mm] 17 ± 1 10 ± 1 β [degrees] 35 ± 3 36 ± 2 k2 – 34 ± 9 37 ± 3 L [mm] 24 ± 5 15 ± 2

Background: Ascending thoracic aortic aneurysm is a chronic degenerative pathology characterized by dilatation of this segment of the aorta. Clinical guidelines use aortic diameter and growth rate as predictors of rupture and dissection. However, these guidelines neglect the effects of tissue remodeling, which may affect wall thickness. The present study aims to systematically review observational studies to examine to what extent wall thickness is considered and measured in clinical practice. Methods: Using PubMed and Web of Science, studies were identified with data on ascending aortic wall thickness, morphology, aortic diameter, and measurement techniques. Results: 15 included studies report several methods by which wall thickness is measured. No association was observed between wall thickness and aortic diameter across included studies. Wall thickness values appear not materially different between aneurysmatic aortas and non-aneurysmal aortas. Conclusions: The effects on and consequences of wall thickness changes during ATAA formation are ill-defined. Wall thickness values for aneurysmatic aortas can be similar to aortas with normal diameters. Given the existing notion that wall thickness is a determinant of mechanical stress homeostasis, our review exposes a clear need for consistent as well as clinically applicable methods and studies to quantify wall thickness in ascending aortic aneurysm research.