Regression of Collateral Function After Recanalization of Chronic Total Coronary Occlusions

Werner, Gerald S.; Emig, Ulf; Mutschke, Oliver; Schwarz, Gero; Bahrmann, Philipp; Figulla, Hans R.

doi:10.1161/01.cir.0000100724.44398.01

Cited by 98 publications

(58 citation statements)

References 34 publications

(39 reference statements)

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“…A rapid reduction in collateral function can be seen after revascularization of a collateral-dependant coronary artery. 3,4 In this case, recanalization of the RCA and restoration of antegrade flow to the RCA perfusion territory resulted in an immediate reduction in collateral function and, consequently, a reduction in the perfusion territory of the LAD. The increase in FFR reflects a reduction in the amount of myocardium supplied by the LAD after recanalization of the RCA.…”

mentioning

confidence: 85%

Reduction in Myocardial Perfusion Territory and its Effect on the Physiological Severity of a Coronary Stenosis

Iqbal

Shah

Khan

et al. 2010

Circ: Cardiovascular Interventions

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A man aged 56 years presented with worsening exertional angina. Coronary angiography showed a moderate-tosevere stenosis in the midleft anterior descending artery (LAD) [ Figure 1a]. The right coronary artery (RCA) was chronically occluded (Figure 1b). A coronary pressure wire assessment of the mid-LAD lesion yielded a fractional flow reserve (FFR) of 0.72, indicating this to be functionally significant (Figure 2a). The patient did not wish to have cardiac surgery, and thus, a percutaneous revascularization strategy was proposed. The RCA was successfully revascularized with 2 drug-eluting stents (Figure 1e). Repeat coronary pressure assessment of the mid-LAD lesion yielded an FFR of 0.84, indicating this to be no longer functionally significant (Figure 2b). Given this result, we decided not to proceed with coronary angioplasty to the LAD. The patient was discharged without antianginal therapy and has been free of anginal symptoms at follow-up. The mechanisms for this change in FFR are discussed below.The FFR is the ratio of the maximum myocardial blood flow in the presence of the coronary stenosis to the maximum myocardial blood flow in the absence of the coronary stenosis. 2 It depends on an interaction among the severity of coronary stenosis, the extent of perfusion territory, and the presence of antegrade and collateral myocardial blood flow. The greater the myocardial perfusion territory distal to a coronary stenosis, the greater the functional significance placed on the stenosis. In the presence of collateral supply to the myocardium distal to a coronary occlusion, the perfusion territory of the occluded vessel becomes incorporated into that of the donor artery supplying the collateral flow. Restoration of antegrade flow in a collateral-dependant coronary artery results in a reduction in collateral flow and function. A rapid reduction in collateral function can be seen after revascularization of a collateral-dependant coronary artery. 3,4 In this case, recanalization of the RCA and restoration of antegrade flow to the RCA perfusion territory resulted in an immediate reduction in collateral function and, consequently, a reduction in the perfusion territory of the LAD. The increase in FFR reflects a reduction in the amount of

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mentioning

confidence: 85%

Reduction in Myocardial Perfusion Territory and its Effect on the Physiological Severity of a Coronary Stenosis

Iqbal

Shah

Khan

et al. 2010

Circ: Cardiovascular Interventions

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“…However, in many patients the age of the CTO cannot be determined with confidence. Furthermore, the temporal criterion used to define a CTO has varied widely in prior reports, typically ranging from Ͼ2 weeks 8,9 to Ͼ3 months, 10 which in part explains interstudy differences in lesion characteristics and procedural success. In general, a total occlusion of duration Ͼ3 months may be considered "chronic.…”

Section: Definitions Prevalence and Clinical Presentation Of Chronimentioning

confidence: 99%

Percutaneous Recanalization of Chronically Occluded Coronary Arteries

et al. 2005

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R emarkable progress in the percutaneous management of coronary artery disease has been achieved over the last decade. The scaffolding properties of coronary stents have resulted in percutaneous coronary intervention (PCI) becoming a predictable procedure, with reduced rates of acute closure and late restenosis compared with balloon angioplasty alone. 1,2 More recently, the site-specific delivery of antiproliferative agents from drug-eluting stents has been demonstrated to markedly attenuate vascular responses leading to neointimal hyperplasia, further reducing the occurrence of clinical and angiographic restenosis to Ͻ10% in most patients. 3,4 PCI in patients with acute coronary syndromes and acute myocardial infarction (AMI) has also been proven to save lives, reduce rates of myocardial infarction (MI), and enhance quality of life compared with alternative treatment modalities. [5][6][7] With these advances in perspective, it is often stated that successful recanalization of chronic total occlusions (CTOs) of native coronary arteries represents the "last frontier" of PCI. This statement is made in deference to the fact that CTOs represent the most technically challenging lesion subset that interventional cardiologists face, with procedural success rates considerably lower than those achieved in nonoccluded coronary vessels or acutely occluded arteries. Moreover, no consensus exists with regard to the definition of CTO, the factors related to procedural failure and/or complications, and the optimal technical approach. Indeed, until recently, the clinical benefits of PCI in CTOs had not been demonstrated.An international panel of 47 physicians from 9 countries was therefore convened in New York City for 2 days in January 2004, the purpose of which was to reach consensus on the current state of the art of CTO angioplasty (see Appendix in the online-only Data Supplement for a complete participant list). This goal was approached through a series of didactic lectures, roundtable discussions, breakout focus groups, and the performance of 14 live case demonstrations of CTO angioplasty by many of the world's most skilled operators in this subspecialty. The present report represents a synthesis of the findings from this meeting and also incorporates a literature review from the field of CTO intervention. Topics covered in Part I of this review include definitions, prevalence, and clinical presentation of CTOs; the anatomy and histopathology of coronary occlusions; experimental CTO models; and the clinical relevance and rationale for CTO revascularization. Part II will review the technical approach to and clinical outcomes after percutaneous intervention of CTOs and describe the novel devices and drugs approved and undergoing investigation for CTO recanalization.

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“…Werner et al 21 have reported that, after an immediate and dramatic drop, the Doppler-derived CFI remains subsequently undiminished for several months. However, in the same study, the authors assessed an alternative index of collateral supply, which suggested a very different pattern of plasticity.…”

Section: Late Collateral Plasticitymentioning

confidence: 99%

Coronary Collaterals Remain Recruitable After Percutaneous Intervention

et al. 2007

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Background-Rapid loss of collateral support has been reported after percutaneous coronary intervention (PCI), leaving the myocardium susceptible to subsequent infarction. However, well-developed collaterals have been found in normal hearts, suggesting that collaterals exist even in the absence of an ischemic stimulus. We assessed the plasticity and determinants of collateral supply after PCI. Methods and Results-Collateral flow index (CFI) was calculated in 60 patients as (P w ϪP v )/(P a ϪP v ) by measurement of aortic (P a ), central venous (P v ), and coronary wedge (P w ) pressures. CFI was reassessed during transient balloon occlusion 5 minutes and 24 hours after PCI in the first 29 patients and at 6 months in the subsequent 25 patients. We also evaluated the relationship between collateral supply, lesion characteristics, and circulating hemopoietic cells numbers before and after successful PCI. CFI at baseline was 0.23Ϯ0.10, with no change 5 minutes and 1 day later (0. 21Ϯ0.12, Pϭ0.62; and 0.22Ϯ0.11, Pϭ0.96, respectively). At 6 months, CFI was 0.14Ϯ0.07 or 63Ϯ27% of the baseline value (PϽ0.001). CFI was proportional to severity of the coronary lesion at baseline (rϭ0.63, PϽ0.0001) but not 6 months after PCI (rϭϪ0.04, Pϭ0.87). The number of circulating CD133 ϩ and CD34 ϩ cells was associated with CFI 6 months after PCI (CD133, rϭ0.59, Pϭ0.035; CD34, rϭ0.63, Pϭ0.037). Conclusions-Coronary collateral flow remains undiminished for at least 24 hours after successful PCI. Functional collateral support subsequently declines but does not regress completely.

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Regression of Collateral Function After Recanalization of Chronic Total Coronary Occlusions

Cited by 98 publications

References 34 publications

Reduction in Myocardial Perfusion Territory and its Effect on the Physiological Severity of a Coronary Stenosis

Reduction in Myocardial Perfusion Territory and its Effect on the Physiological Severity of a Coronary Stenosis

Percutaneous Recanalization of Chronically Occluded Coronary Arteries

Coronary Collaterals Remain Recruitable After Percutaneous Intervention

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