Steven P Marra

M2S, INC., LEB, New Hampshire, United States

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Publications (15)28.44 Total impact

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    ABSTRACT: To quantify dynamic changes in aortoiliac dimensions using dynamic electrocardiographically (ECG)-gated computed tomographic angiography (CTA) and to investigate any potential impact on preoperative endograft sizing in relation to observer variability. Dynamic ECG-gated CTA was performed in 18 patients with abdominal aortic aneurysms. Postprocessing resulted in 11 datasets per patient: 1 static CTA and 10 dynamic CTA series. Vessel diameter, length, and angulation were measured for all phases of the cardiac cycle. The differences between diastolic and systolic aneurysm dimensions were analyzed for significance using paired t tests. To assess intraobserver variability, 20 randomly selected datasets were analyzed twice. Intraobserver repeatability coefficients (RC) were calculated using Bland-Altman analysis. Mean aortic diameter at the proximal neck was 21.4+/-3.0 mm at diastole and 23.2+/-2.9 mm at systole, a mean increase of 1.8+/-0.4 mm (8.5%, p<0.01). The RC for the aortic diameter at the level of the proximal aneurysm neck was 1.9 mm (8.9%). At the distal sealing zones, the mean increase in diameter was 1.7+/-0.3 mm (14.1%, p<0.01) for the right and 1.8+/-0.5 mm (14.2%, p<0.01) for the left common iliac artery (CIA). At both distal sealing zones, the mean increase in CIA diameter exceeded the RC (10.0% for the right CIA and 12.6% for the left CIA). The observed changes in aneurysm dimension during the cardiac cycle are small and in the range of intraobserver variability, so dynamic changes in proximal aneurysm neck diameter and aneurysm length likely have little impact on preoperative endograft selection. However, changes in diameter at the distal sealing zones may be relevant to sizing, so distal oversizing of up to 20% should be considered to prevent distal type I endoleak.
    No preview · Article · Oct 2009 · Journal of Endovascular Therapy
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    ABSTRACT: To evaluate in-vivo thrombus compressibility in abdominal aortic aneurysms (AAAs) to hopefully shed light on the biomechanical importance of intraluminal thrombus. Dynamic electrocardiographically-gated computed tomographic angiography was performed in 17 AAA patients (15 men; mean age 73 years, range 69-76): 11 scheduled for surgical repair and 6 under routine surveillance. The volumes of intraluminal thrombus, the lumen, and the total aneurysm were quantified for each phase of the cardiac cycle. Thrombus compressibility was defined as the percent change in thrombus volume between diastole and peak systole. Continuous data are presented as medians and interquartile ranges (IQR). A substantial interpatient variability was observed in thrombus compressibility, ranging from 0.4% to 43.6% (0.2 to 13.5 mL, respectively). Both thrombus and lumen volumes varied substantially during the cardiac cycle. As lumen volume increased (5.2%, IQR 2.8%-8.8%), thrombus volume decreased (3.0%, IQR 1.0%-4.6%). Total aneurysm volume remained relatively constant (1.3%, IQR 0.4-1.9%). Changes in lumen volume were inversely correlated with changes in thrombus volume (r = -0.73; p = 0.001). In-vivo thrombus compressibility varied from patient to patient, and this variation was irrespective of aneurysm size, pulse pressure, and thrombus volume. This suggests that thrombus might act as a biomechanical buffer in some, while it has virtually no effect in others. Whether differences in thrombus compressibility alter the risk of rupture will be the focus of future research.
    No preview · Article · Jul 2009 · Journal of Endovascular Therapy
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    ABSTRACT: The aim of this study was to explore the possibility that a hybrid aneurysm clip with polymeric jaws bonded to a metal spring could provide mechanical properties comparable to those of an all-metal clip as well as diminished artifacts on computed tomography (CT) scanning. Three clips were created, and Clips I and 2 were tested for mechanical properties. Clip 1 consisted of an Elgiloy spring (a cobalt-chromium-nickel alloy) bonded to carbon fiber limbs; Clip 2 consisted of an Elgiloy spring with polymethylmethacrylate (PMMA) jaws; and Clip 3 consisted of PMMA limbs identical to those in Clip 2 but bonded to a titanium spring. Custom testing equipment was set up to measure the aneurysm clip clamping forces and slippage. Clips 2 and 3 were visualized in vivo using a 64-slice CT unit, and the slices were reformatted into 3D images. According to the testing apparatus, Clip 2 had a similar closing force but less slippage than three similar commercial aneurysm clips. The artifact from the cobalt alloy spring on CT scanning largely offset the advantage of the nonmetal PMMA limbs, which created no artifact. The hybrid titanium/PMMA clip (Clip 3) created very little artifact on CT and allowed visualization of the phantom through the limbs. It is feasible to build a potentially biocompatible hybrid cerebral aneurysm clip with mechanical properties that closely resemble those of conventional metallic clips. Further testing should be directed toward establishing the reliability and biocompatibility of such a clip and optimizing the contour and surface treatments of the polymer
    No preview · Article · Jan 2008 · Journal of Neurosurgery
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    ABSTRACT: Magnetic Resonance Elastography (MRE) has emerged as a noninvasive, quantitative physical means of examining the elastic properties of biological tissues. While it is common to assume simplified elasticity models for purposes of MRE image reconstruction, it is well-accepted that many soft tissues display complex time-dependent behavior not described by linear elasticity. Understanding how the mechanical properties of biological materials change with the frequency of the applied stresses and strains is paramount to the reconstructive imaging techniques used in steady-state MRE. Alternative continuum models, such as consolidation theory, offer the ability to model tissue and other materials comprised of two distinct phases, generally consisting of an elastic solid phase and an infiltrating fluid. For these materials, the time-dependent response under a given load is a function not only of the elastic properties of the solid matrix, but also of the rate at which fluid can flow through the matrix under a pressure gradient. To better study the behavior of the dynamic poroelasticity equations, a three-dimensional finite element model was constructed. Confined, time-harmonic excitation of simulated soil and tissue-like columns was performed to determined material deformation and pore pressure distributions, as well as to identify the influence of the key model parameters under loading conditions and frequencies relevant in steady-state MRE. The results show that the finite element implementation is able to represent the analytical behavior with errors on the order of 1% over a broad range of frequencies. Further, differences between poroelastic and elastic responses in the column can be significant over the frequency range relevant to MRE depending on the value of hydraulic conductivity assumed for the medium.
    No preview · Article · Mar 2007 · Proceedings of SPIE - The International Society for Optical Engineering
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    ABSTRACT: A new inflation test device was developed to study the mechanical properties of aortic tissue. The device was used to measure failure (rupture) strength and to determine the nonlinear, anisotropic elastic properties of porcine thoracic aorta. The tester was designed to stretch initially flat, circular tissue specimens to rupture under uniform biaxial loading. Water was chosen as the pressurizing fluid. Mechanical stretch and radius of curvature during inflation were measured optically in two orthogonal directions, and the Cauchy stress components were calculated from the deformation and the applied pressure. All porcine samples that ruptured successfully did so via a tear in the circumferential direction. Thus, the failure strength was taken to be the stress in the axial direction immediately prior to rupture. The mean failure strength was 1.75 MPa and mean axial stretch at failure was 1.52. These values agree well with published data for other arterial tissues. The nonlinearly elastic deformation behavior was modeled using a hyperelastic constitutive law of the type proposed by Holzapfel et al. [Holzapfel GA, Gasser TC, Ogden RW. J Elasticity 2000;61:1-48]. The results showed that the dominant directions of anisotropy in the porcine aortas were approximately 45 degrees to the axial and circumferential directions, and that the isotropic contribution to the constitutive model was insignificant.
    No preview · Article · Jan 2007 · Cardiovascular Engineering

  • No preview · Article · Dec 2006 · Journal of Biomechanics
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    ABSTRACT: Calcified deposits exist in almost all abdominal aortic aneurysms (AAAs). The significant difference in stiffness between these hard deposits and the compliant arterial wall may result in local stress concentrations and increase the risk of aneurysm rupture. Calcium deposits may also complicate AAA repair by hindering the attachment of a graft or stent-graft to the arterial wall or cause vessel wall injury at the site of balloon dilation or vascular clamp placement. Knowledge of the composition and properties of calcified deposits helps in understanding the risks associated with their presence. This work presents results of elemental composition, microscopic morphology, and mechanical property measurements of human calcified deposits obtained from within AAAs. The elemental analyses indicate the deposits are composed primarily of calcium phosphate with other assorted constituents. Microscopy investigations show a variety of microstructures within the deposits. The mechanical property measurements indicate an average elastic modulus in the range of cortical bone and an average hardness similar to nickel and iron.
    No preview · Article · Oct 2006 · Acta Biomaterialia
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    ABSTRACT: Knowledge of impending abdominal aortic aneurysm (AAA) rupture can help in surgical planning. Typically, aneurysm diameter is used as the indicator of rupture, but recent studies have hypothesized that pressure-induced biomechanical stress may be a better predictor Verification of this hypothesis on a large study population with ruptured and unruptured AAA is vital if stress is to be reliably used as a clinical prognosticator for AAA rupture risk. We have developed an automated algorithm to calculate the peak stress in patient-specific AAA models. The algorithm contains a mesh refinement module, finite element analysis module, and a postprocessing visualization module. Several aspects of the methodology used are an improvement over past reported approaches. The entire analysis may be run from a single command and is completed in less than 1 h with the peak wall stress recorded for statistical analysis. We have used our algorithm for stress analysis of numerous ruptured and unruptured AAA models and report some of our results here. By current estimates, peak stress in the aortic wall appears to be a better predictor of rupture than AAA diameter. Further use of our algorithm is ongoing on larger study populations to convincingly verify these findings.
    No preview · Article · Nov 2005 · Journal of Biomechanical Engineering
  • C. Yang · D. Tang · D. Chen · S.P. Marra · M.F. Fillinger

    No preview · Article · Jan 2005
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    ABSTRACT: The assessment of patient-specific abdominal aortic aneurysm (AAA) rupture risk using finite element (FE) modeling has been shown to be an improvement over current diameter-based prediction techniques (Fillinger, 2002, 2003). However, certain modeling assumptions are made which may have significant effects on the computed AAA wall stresses. For example, the FE meshes are based on composite computed tomography (CT) images obtained during multiple cardiac cycles. This results in meshes that are averaged representations of pressurized AAAs, yet are assumed to represent AAAs at the zero-stress state. Also, the proximal and distal ends of the AAA FE models are assumed to be fixed in place, which may be satisfactory boundary conditions, but have yet to be validated. Recent developments in dynamic magnetic resonance (dMR) imaging allow AAA cross-sectional images to be obtained at multiple locations and time points throughout a cardiac cycle. These images are used to determine the geometries and positions of AAAs at various times throughout the cardiac cycle.
    No preview · Conference Paper · Jan 2004
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    ABSTRACT: We previously showed that peak abdominal aortic aneurysm (AAA) wall stress calculated for aneurysms in vivo is higher at rupture than at elective repair. The purpose of this study was to analyze rupture risk over time in patients under observation. Computed tomography (CT) scans were analyzed for patients with AAA when observation was planned for at least 6 months. AAA wall stress distribution was computationally determined in vivo with CT data, three-dimensional computer modeling, finite element analysis (nonlinear hyperelastic model depicting aneurysm wall behavior), and blood pressure during observation. Analysis included 103 patients and 159 CT scans (mean follow-up, 14 +/- 2 months per CT). Forty-two patients were observed with no intervention for at least 1 year (mean follow-up, 28 +/- 3 months). Elective repair was performed within 1 year in 39 patients, and emergent repair was performed in 22 patients (mean, 6 +/- 1 month after CT) for rupture (n = 14) or acute severe pain. Significant differences were found for initial diameter (observation, 4.9 +/-.1 cm; elective repair, 5.9 +/-.1 cm; emergent repair, 6.1 +/-.2 cm; P <.0001) and initial peak wall stress (38 +/- 1 N/cm(2), 42 +/- 2 n/cm(2), 58 +/- 4 N/cm(2), respectively; P <.0001), but peak wall stress appeared to better differentiate patients who later required emergent repair (elective vs emergent repair: diameter, 3% difference, P =.5; stress, 38% difference, P <.0001). Receiver operating characteristic (ROC) curves for predicting rupture were better for peak wall stress (sensitivity, 94%; specificity,81%; accuracy, 85% [with 44 N/cm(2) threshold]) than for diameter (81%, 70%, 73%, respectively [with optimal 5.5 cm threshold). With proportional hazards analysis, peak wall stress (relative risk, 25x) and gender (relative risk, 3x) were the only significant independent predictors of rupture. For AAAs under observation, peak AAA wall stress seems superior to diameter in differentiating patients who will experience catastrophic outcome. Elevated wall stress associated with rupture is not simply an acute event near the time of rupture.
    Full-text · Article · Apr 2003 · Journal of Vascular Surgery
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    ABSTRACT: Abdominal Aortic Aneurysms (AAAs) are localized enlargements of the aorta. If untreated, AAAs will grow irreversibly until rupture occurs. Ruptured AAAs are usually fatal and are a leading cause of death in the United States, killing 15,000 per year (National Center for Health Statistics, 2001). Surgery to repair AAAs also carries mortality risks, so surgeons desire a reliable tool to evaluate the risk of rupture versus the risk of surgery.
    No preview · Conference Paper · Jan 2003
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    ABSTRACT: The purpose of this study was to calculate abdominal aortic aneurysm (AAA) wall stresses in vivo for ruptured, symptomatic, and electively repaired AAAs with three-dimensional computer modeling techniques, computed tomographic scan data, and blood pressure and to compare wall stress with current clinical indices related to rupture risk. CT scans were analyzed for 48 patients with AAAs: 18 AAAs that ruptured (n = 10) or were urgently repaired for symptoms (n = 8) and 30 AAAs large enough to merit elective repair within 12 weeks of the CT scan. Three-dimensional computer models of AAAs were reconstructed from CT scan data. The stress distribution on the AAA as a result of geometry and blood pressure was computationally determined with finite element analysis with a hyperelastic nonlinear model that depicted the mechanical behavior of the AAA wall. Peak wall stress (maximal stress on the AAA surface) was significantly different between groups (ruptured, 47.7 +/- 6 N/cm(2); emergent symptomatic, 47.5 +/- 4 N/cm(2); elective repair, 36.9 +/- 2 N/cm(2); P =.03), with no significant difference in blood pressure (P =.2) or AAA diameter (P =.1). Because of trends toward differences in diameter, comparison was made only with diameter-matched subjects. Even with identical mean diameters, ruptured/symptomatic AAAs had a significantly higher peak wall stress (46.8 +/- 4.5 N/cm(2) versus 38.1 +/- 1.3 N/cm(2); P =.05). Maximal wall stress predicted risk of rupture better than the LaPlace equation (20.7 +/- 5.7 N/cm(2) versus 18.8 +/- 2.9 N/cm(2); P =.2) or other proposed indices of rupture risk. The smallest ruptured AAA was 4.8 cm, but this aneurysm had a stress equivalent to the average electively repaired 6.3-cm AAA. Peak wall stresses calculated in vivo for AAAs near the time of rupture were significantly higher than peak stresses for electively repaired AAAs, even when matched for maximal diameter. Calculation of wall stress with computer modeling of three-dimensional AAA geometry appears to assess rupture risk more accurately than AAA diameter or other previously proposed clinical indices. Stress analysis is practical and feasible and may become an important clinical tool for evaluation of AAA rupture risk.
    Full-text · Article · Oct 2002 · Journal of Vascular Surgery
  • Steven P. Marra · Francis E. Kennedy · Mark F. Fillinger
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    ABSTRACT: An abdominal aortic aneurysm (AAA) is an abnormal, localized enlargement of the aorta. If untreated, a AAA will continue to enlarge in size and eventually rupture. Currently, AAA diameter is used as the principal indicator of impending rupture. However, this method it is not totally reliable. In an effort to improve the estimation of rupture risk, some researchers are currently studying the mechanical wall stresses of AAAs using patient-specific medical imaging techniques and finite element modeling [1,2]. The accuracy of these models depends significantly on the constitutive law used to describe the mechanical properties of the AAA tissue. To date, only isotropic constitutive laws have been used in these models.
    No preview · Conference Paper · Jan 2002
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    ABSTRACT: The correlation between abdominal aortic aneurysm (AAA) wall stress and risk of rupture was studied by an automated methodology. The finite element method was used to compute the distribution of mechanical stress on the aneurysmal wall. The entire methodology was automated by using a single command line code written in Unix C. The ruptured AAA had higher stresses despite being smaller than the control.
    No preview · Article · Jan 2001

Publication Stats

807 Citations
28.44 Total Impact Points


  • 2009
    • M2S, INC.
      LEB, New Hampshire, United States
  • 2002-2008
    • Dartmouth College
      • Thayer School of Engineering
      Hanover, New Hampshire, United States
  • 2005
    • Hanover College
      Hanover, Maryland, United States
  • 2004
    • Dartmouth–Hitchcock Medical Center
      • Department of Surgery
      Lebanon, New Hampshire, United States
  • 2003
    • University of Iowa
      Iowa City, Iowa, United States