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CLINICAL RESEARCH: CORONARY ARTERY DISEASE

Rapid Decline of Collateral Circulation Increases Susceptibility to Myocardial Ischemia

The Trade-Off of Successful Percutaneous Recanalization of Chronic Total Occlusions

Institute of Cardiology and Center of Excellence on Aging, "G. d’Annunzio" University, Chieti, Italy.

Manuscript received October 4, 2005; revised manuscript received November 29, 2005, accepted December 5, 2005.

^_* Reprint requests and correspondence: Prof. Raffaele De Caterina, Institute of Cardiology, "G. d’Annunzio" University—Chieti, c/o Ospedale S. Camillo de Lellis, Via Forlanini, 50, 66100 Chieti, Italy. (Email: rdecater{at}unich.it).

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 (ST) 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 ST (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.

Abbreviations and Acronyms   CPI = collateral pressure index   CTO = chronic total occlusion   DES = drug-eluting stent   DS = percent diameter stenosis   FFRcoll = collateral fractional flow reserve   FFRcor = coronary fractional flow reserve   FFRmyo = myocardial fractional flow reserve   MLD = minimal lumen diameter   Pa = mean aortic pressure   PCI = percutaneous coronary intervention   Pd = coronary distal pressure   Pv = central venous pressure   Pw = coronary wedge pressure   RefD = reference diameter   TIMI = Thrombolysis In Myocardial Infarction

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