Determinants of Coronary Steal in Chronic Total Coronary Occlusions

Werner, Gerald S.; Fritzenwanger, Michael; Prochnau, Dirk; Schwarz, Gero; Ferrari, Markus; Aarnoudse, Wilbert; Pijls, Nico H.J.; Figulla, Hans R.

doi:10.1016/j.jacc.2005.11.093

Cited by 90 publications

(68 citation statements)

References 37 publications

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“…53 The differential assessment shows that collateral flow is determined by the serial resistance of the collateral donor segment, by the collateral proper, and also specifically by the peripheral microvascular resistance. 54,55 Such a differential assessment requires the use of both pressure and flow velocity recordings.…”

Section: Potential Pitfalls Limitations and Risksmentioning

confidence: 99%

Assessment of the Human Coronary Collateral Circulation

et al. 2010

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Section: Potential Pitfalls Limitations and Risksmentioning

confidence: 99%

Assessment of the Human Coronary Collateral Circulation

et al. 2010

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“…Vasodilation using systemic adenosine in these patients provides a wide variation of responses of the collateral flow and pressure recordings, which are not unidirectional. 36 Angioplasty balloon occlusion of a normal coronary artery for the purpose of CFI measurement may pose a risk for endothelial injury and development of a de novo stenosis. Aside from the shortness of a 1-minute vessel occlusion, the principal feature of our protocol with regard to preventing vessel injury is the use of a low balloon inflation pressure just sufficient to occlude the artery.…”

Section: Potential Pitfalls Limitations and Risksmentioning

confidence: 99%

Assessment and Impact of the Human Coronary Collateral Circulation on Myocardial Ischemia and Outcome

Seiler

2013

Circ: Cardiovascular Interventions

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Appropriate for risk stratification and clinical studies ACS indicates acute coronary syndrome; AP, angina pectoris; CFI p , pressure-derived collateral flow index; CFI v , velocity-derived collateral flow index; CPI, collateral perfusion index; CTO, chronic total (coronary) occlusion; and LV, left ventricle. threshold of 11 heartbeats accurately distinguishes between collateral supply sufficient or insufficient to prevent myocardial ischemia during a brief occlusion (sensitivity of 88%, specificity of 81% 28 ; Table 2). Quantitative Coronary Pressure and Doppler Sensor MeasurementsIn addition to their principle angiographic results, Rentrop et al 27 first described an angioplasty balloon occlusion model using the ratio between distal coronary occlusive or wedge pressure (P occl ) and aortic pressure (P ao ), which correlates with angiographic collateral score groups in patients with 1-vessel CAD (Table 2). 29 In 1987, Meier et al 30 found that a P occl ≥30 mm Hg accurately predicted the presence of spontaneously visible or recruitable collaterals. However, P occl is not dependent only on the amount of collateral flow to the occluded vascular region. Determinants of P occl are the driving pressure across collateral pathways (ie, the pressure difference between the coronary pressure in the collateral supplying and receiving artery), the venous back pressure (central venous or right atrial pressure), but also extravascular pressure related to compression of intramural vessels by cardiac contraction and to transmission of diastolic LV pressure to the epicardial circulation. 31 In this context, in that of microembolization of the collateral-dependent vascular area, P occl should not be used for collateral assessment in the acute coronary syndrome because collateral function is substantially overestimated. In the setting of chronic CAD, LV filling pressure has, however, no influence on P occl unless it exceeds values of 30 mm Hg.In 1993, Pijls et al 32 provided the experimental basis for the determination of maximum coronary and myocardial fractional blood flow by coronary pressure measurements; importantly, the contribution to myocardial blood flow by collateral pathways was assumed negligible. In this study, microvascular resistance during pharmacologically induced hyperemia was postulated to be constant and minimal and, thus, no longer dependent on the degree of epicardial stenoses. As a consequence, coronary pressure should directly reflect coronary flow, the former of which is more easily obtainable during invasive examination than the latter. Therefore, myocardial flow Q distal to a stenosis (the sum of flow through the stenotic vessel plus collateral flow as assumed to be zero) relative to myocardial flow without the stenosis Q N (Q/ Q N =fractional flow reserve, FFR) could be calculated on the basis of distal coronary pressure and aortic pressure both after subtraction of central venous backpressure (CVP). The model was tested in dogs, whereby Doppler-derived measurements of stenotic coronary flow Q s to norm...

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“…In order to generate coronary steal, Werner et al describes, in reference to Gould et al, the following assumption: epicardial stenosis of the donor artery causes a pressure drop proximal to the collateral origin; the collateral resistance is signiicant, and the microvasculature distal to the occlusion lacks a vasodilatory reserve due to being already maximally dilated [38]. Therefore, Werner et al measured fractional low reserve in the donor artery (FFR D ) at the origin of the collaterals in patients with CTO and recorded coronary low velocity and pressure during recanalization.…”

Section: Fractional Low Reserve In the Donor Artery And Coronary Stealmentioning

confidence: 99%

Chronic Total Occlusions

2005

The American Journal of Cardiology

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The following chapter provides a brief overview on the prevalence, clinical features, and histological indings in chronically occluded coronary arteries. The role of coronary collaterals and myocardial viability as well as left ventricular function for the evaluation of treatment strategies of chronic total occlusions (CTO) will be discussed. Imaging modalities such as computed tomography and intracoronary imaging are discussed for their signiicance in CTO assessment and intervention. Finally, important clinical and procedural aspects, latest interventional strategies and techniques, the armamentarium of dedicated tools for CTO interventions, as well as evidence from published trials and clinical research in the ield will be presented.

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Determinants of Coronary Steal in Chronic Total Coronary Occlusions

Cited by 90 publications

References 37 publications

Assessment of the Human Coronary Collateral Circulation

Assessment of the Human Coronary Collateral Circulation

Assessment and Impact of the Human Coronary Collateral Circulation on Myocardial Ischemia and Outcome

Chronic Total Occlusions

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