Aims Collateral arteries are a common but inconsistent finding in coronary heart disease (CHD). We endeavoured to review the methods for coronary artery collateral assessment, the predictors and clinical importance of collateral blood flow, and the potential for therapeutic augmentation of collateral anastomoses. Methods and results While many methods have been used to assess collateral blood flow only a few have been formally validated. Collateral flow index, as determined by measurement of intra-coronary pressure or flow velocity, is the most robust measure of collateral flow. These techniques have led to important advances in our understanding of collateral artery function. Coronary collateral arteries may prevent myocardial ischaemia in healthy subjects and in patients with CHD. A functional collateral circulation may lead to reduced ischaemia, preservation of ventricular function, and an improved prognosis. Recent trials have demonstrated that vascular progenitor cell therapies may improve ventricular function following acute myocardial infarction, raising the possibility of effective biological treatments to improve myocardial blood flow and prognosis in CHD. Conclusions Coronary collateral anastomoses represent a prognostically important adaptive response in patients with CHD. Therapeutic augmentation of collaterals with emerging biological therapies represents a desirable goal for treating CHD patients.

Importance of collateral circulation in coronary heart disease.

Apart from conventional risk factors such as cigarette smoking, obesity, hypertension, diabetes mellitus, hypercholesterolemia, physical inactivity and metabolic syndrome, a family history of coronary artery disease (CAD) seems to be important, especially in young people. Among the genes that may potentially influence the onset and the progression of CAD, there are those controlling the following: renin-angiotensin-aldosterone system (RAAS), adrenergic receptors, paraoxonases, endothelin and nitric oxide synthase. They may modulate the risk of disease onset, as well as its progression and patient prognosis. The unravelling of genetic determinants of CAD may be the first step towards a better understanding of the pathological process involved, the early identification of those at risk and individualizing treatment.

Genetic determinants of cardiovascular disease: the renin-angiotensin-aldosterone system, paraoxonases, endothelin-1, nitric oxide synthase and adrenergic receptors.

Background— Rapid loss of collateral support has been reported after percutaneous coronary intervention (PCI), leaving the myocardium susceptible to subsequent infarction. However, well-developed c...

Coronary Collaterals Remain Recruitable After Percutaneous Intervention

Concurrent coronary artery disease in a vessel remote from a chronic total occlusion (CTO) is common and presents a management dilemma. While the use of adjunctive coronary physiology to guide revascularization is now commonplace in the catheterization laboratory, the presence of a CTO provides a unique and specific situation whereby the physiological assessment is more complex and relies on theoretical assumptions. Broadly, the physiological assessment of a CTO relies on assessing the function and regression of collaterals, the assessment of the microcirculation, the impact of collateral steal as well as assessing the severity of a lesion in the donor vessel (the vessel supplying the majority of collaterals to the CTO). Recent studies have shown that physiological assessment of the donor vessel in the setting of a CTO may overestimate the severity of stenosis, and that after revascularization of a CTO, the index of ischemia may increase, potentially altering the need for revascularization. In this review article, we present the current literature on physiological assessment of patients with a CTO, management recommendations and identify areas for ongoing research.

https://www.ahajournals.org/doi/pdf/10.1161/CIRCINTERVENTIONS.119.007813?download=true

Applicability and Interpretation of Coronary Physiology in the Setting of a Chronic Total Occlusion

Objective—To assess the eVect of recanalisation on collateral flow in a case‐control study in patients with and without chronic total coronary occlusions. Design—In 54 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) (mean (SD) age 61 (6) years), coronary collateral flow was measured by intracoronary pressure or Doppler guide wires at the end of repeated balloon occlusions. Coronary collateral flow index (collateral flow relative to normal antegrade flow) during the first two balloon inflations in 27 patients with a chronic total occlusion (occlusion group) was compared with that of 27 patients matched for age, sex, and collateral flow index at the first occlusion and with a coronary artery diameter stenosis < 80% (stenosis group). Results—Following revascularisation, collateral flow index decreased in 17 of the patients in the occlusion group (63%) and in eight of the patients in the stenosis group (30%) (p = 0.03 between groups). The overall change of collateral flow index between the first and the second balloon occlusion was ˛0.04 (0.01) in the occlusion group (p = 0.07 for paired comparison; from 0.29 (0.17) to 0.25 (0.14)), and +0.02 (0.06) in the stenosis group (p = 0.06 for paired comparison; from 0.27 (0.13) to 0.30 (0.15)). The trend to collateral enhancement in the stenosis group differed significantly from the occlusion group (p = 0.01). Conclusions—While repeated coronary balloon occlusions induce collateral recruitment in the majority of patients with moderate stenoses, recanalisation of chronic total coronary occlusions is more often associated with collateral flow reduction. A later decrease in collateral flow by involution of collateral channels cannot be excluded by this study but has not been reported so far. (Heart 2001;86:438‐443)

https://heart.bmj.com/content/heartjnl/86/4/438.full.pdf

Influence on collateral flow of recanalising chronic total coronary occlusions: a case–control study

Aims

We explored the role of microcirculation integrity following the chronic occlusion of an infarct-related artery to assess the behaviour of collateral circulation during and after reperfusion by coronary angioplasty

Methods and Results

Eighteen patients with a proximally occluded left anterior descending artery and firm evidence of intercoronary collateral circulation were studied with selective coronary angiography and selective intracoronary myocardial contrast echocardiography, before coronary angioplasty, and at 5 and 15min and 12h later. Myocardial enhancement during myocardial contrast echocardiography was evaluated with a semiquantitative score (0–3), which was correlated to basal and 6 months’ regional left ventricular wall motion results. 16/18 procedures were successfully performed; four patients with an inadequate acoustic window were excluded. Restenosis was evident at the 6 months’ follow-up in two patients. Basal myocardial contrast echocardiography indicated that 81/192 segments from the left anterior descending coronary artery and 90/192 from the right coronary artery were perfused; no perfusion was observed in 21 segments either before or after coronary angioplasty. After coronary angioplasty, the angiographic intercoronary collateral circulation immediately disappeared, and myocardial contrast echocardiography revealed that there was a progressive reduction of segments perfused by the right coronary artery and an increase in segments perfused by the left anterior descending coronary artery. Regional left ventricular wall motion analysis demonstrated that there was abnormal motion in 51/192 segments. There was no improvement in segments with score 0 and abnormal motion after 6 months (100% sensitivity), but 16/17 segments with score 3 did show an improvement (98% specificity). The predictive value of intermediate scores (1–2) in detecting long-term improvement, was only 43%.

Conclusion

These data show that the adaptive mechanism observed in the behaviour of epicardial and microvascular circulation after reperfusion of a chronic occluded infarct-related artery can vary. In addition, this study clearly shows that microvascular integrity detected by myocardial contrast echocardiography can provide myocardial viability The European Society of Cardiology

/pdf/coronary-collateral-circulation-behaviour-and-myocardial-3dwpy3hr1l.pdf

Coronary collateral circulation behaviour and myocardial viability in chronic total occlusion treated with coronary angioplasty

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Coronary collateral circulation behaviour and myocardial viability in chronic total occlusion treated with coronary angioplasty