Rapid Decline of Collateral Circulation Increases Susceptibility to Myocardial Ischemia: The Trade-Off of Successful Percutaneous Recanalization of Chronic Total Occlusions Original Research Article

Rapid Decline of Collateral Circulation Increases Susceptibility to Myocardial Ischemia: The Trade-Off of Successful Percutaneous Recanalization of Chronic Total Occlusions Original Research Article Pages 59-65 Marco Zimarino, Arturo Ausiello, Gaetano Contegiacomo, Irene Riccardi, Giulia Renda, Cesare Di Iorio, Raffaele De Caterina Close Close preview | PDF (276 K) | Related articles | Related reference work articles AbstractAbstract | Figures/TablesFigures/Tables | ReferencesReferences Objectives We evaluated the time-behavior of changes in collateral circulation after successful percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in chronic (>1 month) total occlusions (CTO), and assessed their relationship with myocardial ischemia. Background It has been hypothesized that the immediate reduction of collateral flow after PCI of CTO could expose the patients to a higher risk of future ischemic events in the case of vessel reocclusion. Methods In 42 patients with CTO, two consecutive balloon inflations and final DES deployment were performed after positioning of a pressure guidewire. Minimal lumen diameter (MLD), diameter stenosis (DS), angiographic collateral grading (Rentrop score), myocardial (FFRmyo), coronary (FFRcor), and collateral fractional flow reserve (FFRcoll) were evaluated. Chest pain and the sum of ST-segment elevation (ΣST) were analyzed to document the occurrence and extent of myocardial ischemia. Results Percutaneous coronary intervention induced a progressive improvement of indexes of stenosis severity (MLD, DS, Thrombolysis in Myocardial Infarction flow, FFRmyo, and FFRcor) and a rapid reduction in collateral circulation (FFRcoll and Rentrop score). A progressive worsening of ischemia at each balloon inflation occurred, concomitant with the reduction of collateral circulation. At linear regression analysis, an inverse relationship of FFRcoll with ΣST (R2 = 0.352, p < 0.001) and angina pain score (R2 = 0.247, p < 0.001) was observed. Conclusions In CTO, collateral circulation, which provides most coronary flow at baseline, rapidly declines after successful stent implantation and the restoration of an antegrade flow. This rapid de-recruitment of collaterals is likely to put such patients at risk of future ischemic events. Article Outline Methods Study population Study protocol PCI and pressure recordings Angiographic evaluation Clinical and electrocardiographic assessment of ischemia severity Follow-up Statistical analysis Results Procedural outcome Inducibility of ischemia Occlusion age and anatomic pathway of collaterals Follow-up Discussion Collateral modifications after PCI Clinical implications Study limitations Conclusions References