title: Rapid decline of collateral circulation increases susceptibility to myocardial ischemia: the trade-off of successful percutaneous recanalization of chronic total occlusions.
abstract: OBJECTIVE
  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 (SigmaST) 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 SigmaST (R2 = 0.352, p < 0.001) and angina pain score (R(2) = 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.
authors.affiliation: Institute of Cardiology and Center of Excellence on Aging, G. d'Annunzio University, Chieti, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Zimarino
authors.forename: Arturo
authors.initials: A
authors.lastname: Ausiello
authors.forename: Gaetano
authors.initials: G
authors.lastname: Contegiacomo
authors.forename: Irene
authors.initials: I
authors.lastname: Riccardi
authors.forename: Giulia
authors.initials: G
authors.lastname: Renda
authors.forename: Cesare
authors.initials: C
authors.lastname: Di Iorio
authors.forename: Raffaele
authors.initials: R
authors.lastname: De Caterina
mesh_terms: D000368:Aged; D000787:Angina Pectoris / Q000209:etiology*; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects; D003097:Collateral Circulation; D017023:Coronary Angiography; D003326:Coronary Circulation; D023903:Coronary Restenosis; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017239:Paclitaxel / Q000008:administration & dosage; D020123:Sirolimus / Q000008:administration & dosage; D015607:Stents
chemical_list: D017239:Paclitaxel; D020123:Sirolimus