Evaluation of ascending aorta and radial artery elasticity in patients with type 2 diabetes mellitus via velocity vector imaging

Introduction

Vascular complications of diabetes mellitus (DM), characterized by increased arterial stiffness, pose a severe threat to human health (1). Approximately 50% of diabetes patients die of vascular complications (2). Even after normalization of their blood glucose concentration, the long-term negative effects of prolonged high blood sugar on blood vessels still exist. This phenomenon is called “metabolic memory” or “hyperglycemic memory” (3). Therefore, early and sensitive assessment of arterial wall elasticity is particularly important for detecting subclinical atherosclerosis in this patient population (4).

The ascending aorta (AA) is the largest blood vessel and is located near the heart. Research (5) has shown that early atherosclerosis in type 2 DM (T2DM) patients mainly occurs in the aorta rather than the distal artery, and a decrease in aortic elasticity is an important predictor of atherosclerosis and other cardiovascular (CV) events (6,7). The radial artery (RA) is utilized in many important clinical applications due to its efficacy and safety, such percutaneous coronary interventions, serving as a bridging vessel for coronary artery bypass surgery, and facilitating trans-radial hemodialysis (8). RA elasticity assessment, as a supplement, can provide the user with an instant analysis of the patient’s arterial stiffness. It can accurately determine the scope and degree of vascular lesions and comprehensively reflect the health status of the systemic arterial system. Moreover, RA ultrasound examination can be performed in nearly any clinic setting, is easy and affordable to perform, and has a potential advantage over more classic approaches such as carotid imaging.

At present, the clinical evaluation of arterial status in diabetes patients is mainly through traditional ultrasound to observe the intima-media thickness and plaque formation in the carotid and lower limb arteries, but its sensitivity is low. Although some studies have evaluated aortic elasticity in diabetes patients via M-mode echocardiography, few studies have investigated aortic elasticity from the perspective of biomechanics. Moreover, there are few studies on RA elasticity in diabetes patients, and the data in the literature remain controversial.

Velocity vector imaging (VVI) can be used to evaluate the biomechanical characteristics of large- and medium-sized arteries and reflect their elasticity (9,10). Kim et al. first applied this technique to investigate the usefulness of vascular strain analysis and evaluate arterial stiffness, and showed that peak circumferential strain and fractional area change (FAC) measured by VVI were significantly associated with parameters of arterial stiffness measured via pulse wave velocities (PWVs), which is the recommended gold standard approach to the measurement of arterial stiffness (11).

In this study, VVI technology was used to detect the elasticity of the AA and RA in T2DM patients, and correlation analysis was performed with clinical risk factors. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-967/rc).

Methods

Study population

This cross-sectional study was approved by the Institutional Ethics Committee of Second Xiangya Hospital of Central South University, Changsha, China (Approval Number: 2021 No. 162). Patients with T2DM who visited our endocrine clinic from June 2022 to August 2024 were included in this study. The diagnosis of T2DM was made according to the 2022 guidelines of the American Diabetes Association (12). The exclusion criteria were as follows: poor image quality due to obesity, emphysema or motion artifacts (13-15); pregnancy, hypertension, coronary heart disease, valvular heart disease, cardiomyopathy, severe arrhythmia, preexisting aortic disease and congenital heart disease. A total of 50 T2DM patients were included in the final analysis. We enrolled 52 non-diabetic controls who were age- and sex-matched and without DM or any history of CV disease. Informed consent was obtained from all the subjects. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

General clinical and biochemical parameters

A detailed medical history inquiry and comprehensive examination were conducted for all the subjects. Electrocardiogram data, fasting blood samples, fasting plasma glucose (FPG) levels, high-density lipoprotein cholesterol (HDL-C) levels, triglyceride (TG) levels, low-density lipoprotein cholesterol (LDL-C) levels, total cholesterol (TCH) levels, and glycosylated hemoglobin (HbA1c) levels were obtained. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurements were performed after all participants had rested quietly for 5 to 10 minutes according to the guidelines of the American Heart Association (16).

Echocardiographic examination

An experienced doctor who have more than 6 years of imaging experience and received CV ultrasound training performed a standard transthoracic echocardiogram using a 4V1C probe (2.0–4.0 MHz) on the ACUSON SC2000 ultrasound system (Axius, Malvern, Pennsylvania, USA) developed by Siemens Healthineers. The doctor had no knowledge of the patient group status. The left atrial diameter (LAD) and left ventricular mass index (LVMI) were recorded, and early diastolic mitral inflow velocity (E) and early diastolic average mitral annular velocity (e′) were obtained following the American Society of Echocardiography guidelines (17). The left ventricle global longitudinal strain (GLS) was analyzed with VVI software.

Arterial elasticity examination

Dynamic images of the AA in the long and short axes were collected as previously described on the ACUSON SC2000 ultrasound system (18). Similarly, the operator measured the RA diameter at a distance of 2–3 cm from the right wrist and collected dynamic images of the RA along the long and short axes with a linear array transducer (18L6, 5–18 MHz) on the ACUSON S2000 ultrasound system (Axius, Malvern, Pennsylvania, USA) developed by Siemens Healthineers. All two-dimensional dynamic images were analyzed with VVI software (Axius, Siemens Medical, Solutions), which automatically tracks the vascular intima marker points and generates strain curves to record the ascending aortic mean longitudinal strain (ALS), ascending aortic global circumferential strain (ACS), ascending aortic FAC, radial arterial mean longitudinal strain (RLS), and radial arterial global circumferential strain (RCS).

Statistical analysis

All the statistical analyses were performed via GraphPad Prism 9 (GraphPad Software, Inc., San Diego, CA, USA). Data are presented as the median (range) or frequency (percentage). A Kolmogorov-Smirnov test was performed to evaluate whether the data distribution is normal. Data were compared between groups using Student’s t-test, the Mann-Whitney U test, the Chi-squared test or Fisher’s exact test as appropriate. The arterial elasticity parameters were evaluated by a paired t-test. Spearman correlation coefficients were calculated to demonstrate the relationship between arterial elasticity parameters and clinical risk factors in T2DM patients. To determine whether the differences in arterial elasticity indices between the T2DM and non-diabetic groups were independent of blood pressure, we employed generalized linear models (GLM). In the models, arterial elasticity indices served as the dependent variable, with group status (T2DM vs. non-diabetic control) as the primary independent factor. SBP and DBP were included as covariates to control for potential confounding. Visual display of inter observer and intra observer consistency utilized the intra-class correlation coefficient (ICC), which was used to test the inter-observer and intra-observer variability from the stored images of 40 randomly selected observations. Inter-observer measurement was performed by L.Y. and another echo-cardiographer (Lei Gao, who is not a coauthor), and intra-observer measurements were repeated by L.Y. the next day. ICC ≥0.75 means good reliability. P<0.05 was considered to indicate statistical significance.

Results

Compared with those in non-diabetic individuals, FPG and HbA1c in diabetic patients were significantly greater (P<0.01). There was no statistically significant difference in SBP, DBP, TCH, TG, HDL-C or LDL-C between the two groups (P>0.05). Patients with T2DM presented higher E/e′ values and lower GLS (P<0.05). Detailed information regarding these indices is presented in Table 1.

Compared with the control group, the T2DM group presented significantly lower ALS, ACS, FAC, RLS and RCS values. The inner diameter of the AA was greater in patients with T2DM. There were no significant differences in the inner diameter of the RA between controls and T2DM patients. Detailed information is provided in Table 2, Figures 1-3.

Figure 1 Measurement of elasticity of ascending aorta. Longitudinal strain curves of ascending aorta (A), circumferential strain curves of ascending aorta (B), fractional area change of ascending aorta (C) are shown for control individuals. Longitudinal strain curves of ascending aorta (D), circumferential strain curves of ascending aorta (E), fractional area change of ascending aorta (F) are shown for patients with type 2 diabetes mellitus.

Figure 2 Measurement of elasticity of radial artery. Longitudinal strain curves of radial artery (A) and circumferential strain curves of the radial artery (B) are shown in control individuals. Longitudinal strain curves of radial artery (C) and circumferential strain curves of the radial artery (D) are shown in patients with type 2 diabetes mellitus. The arrows represent the average strain values of the anterior and posterior walls of the radial artery.

Figure 3 Comparison of arterial elasticity indices. Comparison between the diabetes group and control group of the: (A) longitudinal strain of the ascending aorta, (B) circumferential strain of the ascending aorta, (C) fractional area change of the ascending aorta, (D) longitudinal strain of the radial artery, (E) circumferential strain of the radial artery. *, indicates P<0.05 (B: P=0.04; C: P=0.03; E: P=0.01). ***, indicates P<0.001 (A: P=0.0008; D: P=0.0002). ACS, ascending aortic global circumferential strain; ALS, ascending aortic mean longitudinal strain; FAC, ascending aortic fractional area change; RCS, radial arterial global circumferential strain; RLS, radial arterial mean longitudinal strain; T2DM, type 2 diabetes mellitus.

Our results revealed that in the T2DM group, HbA1c and diabetes duration were significantly negatively correlated with the arterial elasticity parameters ALS, ACS, FAC, RLS and RCS (all P<0.01). FPG was significantly negatively correlated with the ALS (P<0.05) (Figure 4).

Figure 4 Correlations between indices of arterial elasticity and clinical and echocardiographic features. A correlation coefficient close to 1 indicates a strong positive correlation, close to −1 indicates a strong negative correlation, and close to 0 indicates no significant correlation. Orange represents a positive correlation, blue represents a negative correlation, and darker colors indicate a stronger correlation. ACS, ascending aortic global circumferential strain; ALS, ascending aortic mean longitudinal strain; E/e′, the ratio of pulsed Doppler early transmitral peak flow velocity and early diastolic mitral annular velocity; FAC, ascending aortic fractional area change; FPG, fasting blood glucose; GLS, left ventricle global longitudinal strain; HbA1c, glycosylated hemoglobin; RCS, radial arterial global circumferential strain; RLS, radial arterial mean longitudinal strain.

T2DM was significantly associated with alterations in arterial elasticity parameters after adjusting for both systolic and diastolic blood pressure. Specifically, T2DM was linked to a significant decrease in the ALS (β=−3.814, P=0.029), ACS (β=−2.088, P=0.038), RLS (β=−3.025, P=0.032), and RCS (β=−2.179, P=0.041), suggesting that the reduced elasticity in these parameters is independent of blood pressure.

The ICCs for intra- and inter-observer variability were 0.775–0.883 and 0.762–0.924, respectively, which indicated that the measurements of all arterial elasticity parameters had a high consistent in inter-observer and intra-observer (Table 3).

Discussion

To our knowledge, this study is the first to use VVI to demonstrate decreased AA and RA elasticity in patients with T2DM from the perspective of biomechanics. This study also revealed that impaired arterial elasticity parameters were negatively correlated with HbA1c and diabetes duration and partly correlated with FPG levels.

Compared with those in the control group, the ALS, ACS, RLS and RCS of the T2DM patients were significantly lower, suggesting reduced ascending aortic and RA wall deformation in the longitudinal and circumferential directions. The FAC, which reflects the change in the cross-sectional area of the AA wall, was also significantly reduced in T2DM patients. These biomechanical parameters derived from VVI could reflect arterial elasticity and have been shown to be significantly negatively correlated with the collagen content in wall tissue and the amount of soluble elastin fragments in the plasma (19,20). In an in vivo experimental study, Lorentzen et al. assessed the biomechanical properties of the aorta in HAS-2 transgenic mice and reported that hyperglycemia induced by hyaluronan accumulation increased aortic stiffness and strength (21).

One of the key factors contributing to diabetic vascular disease is the accumulation of advanced glycation end products (AGEs). Yuan et al. found that AGEs induce proliferation and migration of human aortic smooth muscle cells through the phosphatidylinositol-3-kinase/protein kinase B signaling pathway, thereby promoting arterial remodeling (22). Additionally, in diabetes, AGEs can cross-link with collagen and elastin, resulting in altered biomechanical properties of the arterial wall and decreased compliance (23). Oxidative stress, inflammatory response and endothelial dysfunction also promote the degradation of the extracellular matrix of blood vessels through multiple pathways as a coordinated action of reactive oxygen and inflammatory factors, which activate matrix metalloproteinases (MMPs), promoting the cleavage and degradation of collagen and elastin (24). In diabetes mellitus, the activity of hyaluronic acid synthase is increased, which activates the hyaluronic acid/CD44 signaling pathway to transform vascular smooth muscle cells from the contractile type to the synthetic type, promoting the secretion of extracellular matrix and further aggravating the stiffness of the arterial wall (25). In brief, the accumulation of AGEs, oxidative stress, inflammation, endothelial dysfunction and activation of hyaluronic acid synthase cause an imbalance between the production and degradation of collagen and elastic fibers of the artery wall and decreased arterial compliance, leading to vascular stiffness and vascular dysfunction, including reduced longitudinal and circumferential strain of the artery (26).

Various other studies have also confirmed changes in aortic elasticity in diabetes patients by using different ultrasound techniques. For example, Su et al. applied strain rate imaging (SRI) to assess aortic wall elasticity and reported that the anterior and posterior wall displacement, strain, and strain rate of the aorta in T2DM patients were significantly lower than those in controls (27). A cross-sectional study by Dang et al. via M-mode echocardiography also revealed that the aortic stiffness index was significantly greater in patients with T2DM than in healthy subjects. Moreover, aortic strain, aortic compliance, and aortic distensibility are lower in T2DM patients (28). Additionally, Song’s study demonstrated that the AA was stiffer in the T2DM group compared with that in healthy subjects (29). Using pulsed wave Doppler tissue imaging, Badran et al. found that the aortic wall systolic velocity was significantly lower in patients compared with the control group and concluded that poor glycemic control and the duration of diabetes have detrimental effects on aortic elastic properties (30).

In this study, intriguingly, we also found that radial arterial longitudinal and circumferential strain were significantly lower in T2DM patients. This finding was inconsistent with the findings of Catalano et al. They included 19 patients with T2DM and reported that the distensibility and compliance did not differ significantly from those of the controls (31). This inconsistency may be attributed to the number of subjects and the different technologies used. The SRI has an angle-dependent defect. M-mode echocardiography, whose parameters depend on static equations, cannot be used to measure and assess aortic axial elongation and deformation. However, VVI can be used to comprehensively evaluate longitudinal and circumferential deformations in real time, dynamically, and without angle dependence (10). Many studies have shown that diabetes leads to intima-media thickening and wall calcification of the RA, and even patients with prediabetes have a greater prevalence of subclinical RA atherosclerosis (32,33). VVI can also be used to study the elasticity of peripheral arteries, Yang et al. using Speckle-Tracking and found that the strain measures of carotid arteries were significantly lower in patients with diabetes even after adjustment for age, sex, race, and hemodynamic parameters. These results further confirm the harmful effects of high blood sugar on the peripheral arteries (13).

In this study, we also found that there were significant correlations between arterial elasticity parameters and FPG, HbA1c, and diabetes duration, indicating that poor blood glucose control directly reduces the elasticity of the AA and RA. In particular, HbA1c may be a useful marker of decreased arterial elasticity in T2DM patients (34). Moreover, the longer the duration of diabetes, the higher the risk of arterial elastic impairment. Sustained hyperglycemia or prolonged pathological processes eventually lead to vascular endothelial damage and decreased arterial elasticity (35).

There are several limitations in this study. First, VVI has a strong dependence on image quality and requires a clear display of vascular intima boundaries. Patients with obesity or emphysema may be unable to be examined by VVI. Second, VVI examination takes a long time, around 15 to 20 minutes for a single vessel. Third, only T2DM patients were included in this study, and T2DM patients often have hypertension, coronary heart disease and other CV diseases. Thus, a larger sample size is essential in the future.

Conclusions

In conclusion, the elasticity of the AA and RA in T2DM patients was impaired. Decreased arterial elasticity was associated with poor blood glucose control and a longer duration of diabetes. VVI seems to be a reliable noninvasive technique for assessing arterial elasticity. Further studies are needed to assess the clinical value of VVI findings for predicting future cardiac events.

Acknowledgments

We thank all the patients and control subjects for their participation in this study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-967/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-967/dss

Funding: This work was supported by the Natural Science Foundation of Hunan Province (No. 2024JJ8122).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-967/coif). All authors report that this work was supported by the Natural Science Foundation of Hunan Province (No. 2024JJ8122). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This cross-sectional study was approved by the Institutional Ethics Committee of Second Xiangya Hospital of Central South University, Changsha, China (Approval Number: 2021 No. 162). Informed consent was obtained from all the subjects. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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