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CLINICAL RESEARCH: INVASIVE AND INTERVENTIONAL CARDIOLOGY

Determinants of target vessel failure in chronic total coronary occlusions after stent implantation

The influence of collateral function and coronary hemodynamics

^* Clinic for Internal Medicine III, Friedrich-Schiller-University, Jena, Germany

Manuscript received December 19, 2002; revised manuscript received March 19, 2003, accepted April 3, 2003.

^* Reprint requests and correspondence: Dr. Gerald S. Werner, Klinik für Innere Medizin III, Friedrich-Schiller-Universität, Erlanger Allee 101 D-07740, Jena, Germany.
gerald.werner{at}med.uni-jena.de

OBJECTIVES: The goal of this study was to assess the influence of collateral function, coronary hemodynamics, and the angiographic result on the risk of target vessel failure (TVF) after recanalization of a chronic total coronary occlusion (CTO).

BACKGROUND: Collaterals may have an adverse effect on TVF.

METHODS: In 111 consecutive patients, a CTO (duration >2 weeks) was successfully recanalized with stent implantation. Collateral function was assessed by intracoronary Doppler flow velocity and pressure recordings distal to the occlusion. Baseline collateral function was determined before the first balloon inflation, and recruitable collateral function after stenting during a balloon reocclusion. Finally, the coronary flow velocity reserve (CFVR) and the fractional flow reserve (FFR) were measured.

RESULTS: Angiographic follow-up after 5 ± 1.4 months in 106 patients showed a reocclusion in 17% and a restenosis in 36%. The major determinants of TVF were the stent length (p < 0.01) and number of implanted stents (p < 0.01). No difference was observed in baseline or recruitable collateral function between patients with and without TVF; 52% of patients had a CFVR 2.0, and only 18% a CFVR 2.5 after percutaneous transluminal coronary angioplasty, but neither cutoff-value predicted TVF. A low FFR discriminated patients with reocclusion (0.81 ± 0.07 vs. 0.86 ± 0.08, p < 0.05) but not with restenosis (0.87 ± 0.06).

CONCLUSIONS: This study showed that there is no relation between a well-developed collateral supply and the risk of TVF in recanalized CTOs. This was rather determined by the stented segment length. There was also no adverse effect of the frequently observed impaired CFVR on TVF, whereas a low FFR was associated with a higher risk of reocclusion.

Abbreviations and Acronyms   APV = average peak velocity   CFVR = coronary flow velocity reserve   CPI = collateral pressure index   CTO = chronic total coronary occlusion   CVP = central venous pressure   FFR = fractional flow reserve   LV = left ventricular   MI = myocardial infarction   MLD = minimum lumen diameter   PAo = mean aortic pressure   PD = mean pressure distal to the lesion   POccl = mean pressure distal to the occlusion   PTCA = percutaneous transluminal coronary angioplasty   TVF = target vessel failure

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