Misinterpretation of Stenosis Severity in the Presence of Serial Coronary Stenoses

Diagnosis of the functional severity of an epicardial coronary stenosis using parameters like Fractional Flow Reserve, FFR (ratio of distal to proximal pressure of a stenotic region), might be affected in the presence of an additional downstream stenosis. In order to assess this effect, we have performed an in-vitro experiment which is used to validate a computational study. Three combinations of serial stenoses were tested: 80%-64%, 80%-80% and 80%-90% area stenosis (AS). The physiological mean hyperemic flow (flow at maximal arterial dilatation) values were obtained using an in-vitro experimental set-up. These flow rates were used as steady flow inputs by time-averaging the spatially averaged flow pulse over two cardiac cycles for the computational study. FFR values were calculated at hyperemic flow using both the experimental and numerical pressure data. As the downstream severity increased from 64% AS to 80% AS, hyperemic coronary flow decreased from 136.4 ml/min to 126.4 ml/min. Flow decreased further to 90.7 ml/min with a downstream severity of 90% AS. FFR of the intermediate stenosis increased from 0.76 to 0.79 and further to 0.88 as the downstream stenosis increased from 64% to 80% with a final severity of 90% AS. Similarly, numerically obtained FFR values increased to 0.83, 0.80 and 0.92 for the corresponding cases indicating an error within 7% of the experimental values. These results indicate that the presence of a downstream stenosis might lead to a clinical misinterpretation of the upstream stenosis severity.