The coronary collateral circulation in living man

doi:10.1016/0002-9149(69)90434-2

The American Journal of Cardiology

Volume 24, Issue 3, September 1969, Pages 393-400

https://doi.org/10.1016/0002-9149(69)90434-2 Get rights and content

Abstract

The coronary arteriograms of 100 patients studied in our laboratory were reviewed and searched for the presence or absence of coronary collaterals. Fiftythree had either normal coronary arteriograms or less than 50 per cent lumen reduction. We found no collaterals in this group.

The remaining 47 patients had more than 50 per cent lumen reduction of one or more of the main trunks or major branches. There was collateral circulation in 37 cases. Five had normal electrocardiograms. In 13, the existence of collaterals was inferred by visualization of an artery distal to a complete occlusion or from its opacification after injection of contrast agent into the heterolateral artery. In the remaining 24, continuity could be traced from the feeding artery through the collateral vessel into the recipient vessel. We describe several patterns of anastomotic pathways. The presence of coronary collaterals is a reliable indication of severe coronary artery disease and may account for a normal resting electrocardiogram even in patients with major arterial occlusion.

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Cited by (162)

Immediate recruitment of dormant coronary collaterals can provide more than half of normal resting perfusion during coronary occlusion in patients with coronary artery disease
2023, Journal of Nuclear Cardiology
Dormant coronary collaterals are highly prevalent and clinically beneficial in cases of coronary occlusion. However, the magnitude of myocardial perfusion provided by immediate coronary collateral recruitment during acute occlusion is unknown. We aimed to quantify collateral myocardial perfusion during balloon occlusion in patients with coronary artery disease (CAD).
Patients without angiographically visible collaterals undergoing elective percutaneous transluminal coronary angioplasty (PTCA) to a single epicardial vessel underwent two scans with 99mTc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT). All subjects underwent at least three minutes of angiographically verified complete balloon occlusion, at which time an intravenous injection of the radiotracer was administered, followed by SPECT imaging. A second radiotracer injection followed by SPECT imaging was performed 24 h after PTCA.
The study included 22 patients (median [interquartile range] age 68 [54-72] years. The perfusion defect extent was 19 [11-38] % of the LV, and the collateral perfusion at rest was 64 [58-67]% of normal.
This is the first study to describe the magnitude of short-term changes in coronary microvascular collateral perfusion in patients with CAD. On average, despite coronary occlusion and an absence of angiographically visible collateral vessels, collaterals provided more than half of the normal perfusion.
Three-dimensional visualization of coronary microvasculature in rats with myocardial infarction
2020, Microvascular Research
Citation Excerpt :
The opening of the pre-existing vascular access is a chronic process following repeated myocardial ischaemic stimulation or acute vascular occlusion, which allow to increases the potential vascular access, increase the lumen, and results in increased functional blood flow (Charney and Cohen, 1993; Fujita et al., 1987; Juilliere et al., 1990). Although potential reservoir vascular access has long been suggested, only the opening state of blood vessels with diameter above 100 μm were confirmed (Gensini and Bruto da Costa, 1969). The number, diameter and opening state of microvessels with diameters below 50 μm were not fully understood in the previous study of microcirculation.
Assessment of the coronary microcirculation remains challenging.
we explored the feasibility of evaluating the coronary microvasculature in rats with myocardial infarction (MI) using a three-dimensional visualization technique.
Animals were divided into the sham operation group (S), MI 45 min group (M45), and MI 180 min group (M180). Opened microvessels were labelled with the fluorescent dye DiI (1, 1′-dioctadecyl-3, 3, 3′3′-tetramethylindo carbocyanine perchlorate) using a heart perfusion method. The microvascular distribution and opening status were observed under laser scanning confocal microscopy, which was adjusted to facilitate evaluation of subjects around 6 to 20 μm.
Microvascular vessels (6-20 μm) were successfully labelled by DiI. Intact and clear three-dimensional microvascular structures were observed in myocardium of sham rats and remote non-infarct myocardial tissue of MI rats, while there was almost no microvascular structure in the infarct area of the M45 group, and only a small amount of microvascular visualization was visualized in the infarct area of the M180 group. The microvascular area and microvascular density in M45 group and M180 group in the infarct border zone were significantly lower than corresponding area in S group.
Three-dimensional visualization of opened coronary microvascular vessels is feasible in DiI-labelled myocardium in this rat MI model. This novel technique might be useful for defining the underlying mechanisms of coronary microvascular diseases and observe the efficacy of various therapy strategies on coronary microvessels.
The collateral circulation of the heart in coronary total arterial occlusions in man: Systematic review of assessment and pathophysiology
2013, American Heart Journal
Citation Excerpt :
Microcirculatory dysfunction distal to occluded arteries is also a major factor in response to medical therapy and revascularization. Historically, there have been conflicting accounts of the protective role of coronary collaterals with clear evidence of benefit in some studies,6 whereas others reveal no evidence of a protective effect.80,85 Differing patient populations and the confounding effect of more advanced disease associated with greater collateralization is likely to explain these differences.76
Anatomical and functional assessment of the collateral circulation of the heart in total arterial occlusions is challenging, and this is particularly true of the microcirculation. The pathophysiology of the collateral circulation has historically been and remains of considerable research focus but with diverging and sometimes conflicting results. Our purpose was to conduct a systematic review on the assessment and pathophysiology of the collateral circulation of the heart in total coronary arterial occlusions.
We extracted data from Pubmed, Ovid, EMBASE, and Cochrane database from 1966 to December 2012. Two investigators independently reviewed the identified articles for eligibility and extracted the data.
Seventy-seven studies met inclusion criterion. An invasive assessment of the collateral circulation with pressure and/or Doppler wires is the gold standard in the assessment of collateral physiology and anatomy, although this can only be undertaken after successful passage of the sensor in the true lumen of the occluded vessel. A collateral circulation can provide resting metabolic requirements for the heart but invariably cannot meet demands on stress irrespective of the degree of collateralization as assessed by coronary angiography. In the case of myocardium subtending a totally occluded epicardial artery coronary collateral grading systems or physiological assessment of collateral flow is only moderately sensitive and poorly specific at predicting viability. Regression of collaterals seems more profound in totally occluded arteries versus nonoccluded lesions postrevascularization.
Key controversies in the assessment and pathophysiology of the collateral circulation of the heart in total coronary arterial occlusions are systematically evaluated.
Duration of ischemia is a major determinant of transmurality and severe microvascular obstruction after primary angioplasty: A study performed with contrast-enhanced magnetic resonance
2005, Journal of the American College of Cardiology
Citation Excerpt :
The presence of collateral blood flow is an alternative source of blood supply to a myocardium jeopardized by abrupt occlusion of the vessel, and it has been shown to preserve the myocardium in acute phase of MI, favoring improvement in left ventricular function after successful primary PCI (25). However, coronary angiography, the most commonly used technique for studying collateral circulation, may not be accurate in assessing collateral circulation because most collateral vessels are too small to be angiographically visualized (26). In our study, the limited number (n = 2) of patients with evident collateral circulation does not allow definitive conclusions.
This study sought to assess the relationship between duration of ischemia and both myocardial transmural necrosis (TN) and severe microvascular obstruction (SMO), by contrast-enhanced magnetic resonance (CE-MR), in patients with acute myocardial infarction (AMI) treated with angioplasty (PCI), and to estimate the risk of TN and SMO with the duration of ischemia.
The impact of ischemic time on myocardial and microvascular injury is not well characterized in people.
We performed CE-MR in 77 patients with first AMI, 5 ± 3 days after successful PCI. The AMI was labeled as transmural if hyperenhancement at CE-MR was extended to ≥75% of the thickness in two or more ventricular segments. The SMO was identified as areas of late hypoenhancement surrounded by hyperenhanced tissue. The relationship between ischemic time and CE-MR evidence of SMO or TN was evaluated by logistic regression.
Thirteen patients were excluded because of preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 of the infarct-related artery. For the remaining 64 patients, the mean time to treatment was 190 ± 110 min, 45 (65%) patients had TN and 23 (39%) had SMO. Mean pain to balloon time was 90 ± 40 min, 110 ± 107 min, and 137 ± 97 min in patients without TN and SMO, with TN but without SMO, or with both TN and SMO, respectively (p = 0.001). Multivariate analysis showed that time delay was significantly associated both with TN (odds ratio per 30 min, 1.37, p = 0.032), and SMO (odds ratio per 30 min, 1.21; p = 0.021).
In AMI patients with impaired coronary perfusion undergoing PCI, the risk of TN and SMO increases with the duration of the ischemic time.
Myocardial contrast echocardiography assessment of acute changes in collateral perfusion of contralateral coronary artery with coronary flow reserve after coronary angioplasty
2005, Journal of the American Society of Echocardiography
Coronary flow velocity reserve (CFVR) is used to evaluate the severity of epicardial and intramyocardial coronary artery disease. Collateral flow to an adjacent compromised myocardial territory may influence the CFVR of a specific artery.
To assess the impact of collateral flow on CFVR, we measured CFVR and assessed perfusion area (PA) with myocardial contrast echocardiography in the right coronary arteries of 18 patients with total/subtotal occlusion of the left anterior descending coronary artery before and after angioplasty. A total of 10 patients had well-developed collaterals emerging from the right coronary artery (group I) and 8 patients did not (group II). Using a Doppler-tipped guidewire, we measured CFVR, which is defined as the ratio of papaverine-induced hyperemic average peak velocity of coronary flow to baseline.
Before angioplasty of the left anterior descending coronary artery, CFVR was significantly reduced in group I compared with group II (2.35 ± 0.47 vs 3.26 ± 0.54, P < .01). Baseline average peak velocity in group I before angioplasty was significantly greater than that after angioplasty (23.7 ± 11.6 vs 19.2 ± 9.7 cm/s, P < .05). After angioplasty, CFVR immediately increased in group I to 3.46 ± 0.54 (P < .001). The increase in CFVR was well correlated with the decrement in PA after angioplasty (r = 0.883, P < .001).
The CFVR of an artery that supplies extensive collaterals is limited because of an elevation in the baseline resting flow velocity. This restriction in CFVR improves proportionally with decreases in PA that occurs after angioplasty of the ipsilateral coronary artery. These data suggest that PA, in addition to coronary artery structure, influences CFVR.
Relationship between contractile reserve, TI-201 uptake, and collateral angiographic circulation in collateral-dependent myocardium: Implications regarding the evaluation of myocardial viability
2003, Journal of Nuclear Cardiology
Background. The aim of this study was to compare collateral angiographic circulation (CC), thallium 201 single photon emission computed tomography (SPECT), low-dose dobutamine echocardiography (LDDE), and their combination in identifying viable myocardium beyond a chronic occlusion. Methods and Results. We studied 33 consecutive patients with a chronic occluded coronary artery and regional ventricular dysfunction who underwent dobutamine infusion (5–10 μg · kg^–1 · min^–1), Tl-201 SPECT, and coronary revascularization (15 patients underwent coronary artery bypass grafting and 18 patients percutaneous transluminal coronary angioplasty). Echocardiography and Tl-201 SPECT at rest were repeated 90 ± 48 days after revascularization. For viability assessment, Tl-201 SPECT showed the best sensitivity and accuracy (77% and 72%, respectively) compared with LDDE (64% and 63%, respectively) and CC (74% and 55%, P < .05 vs Tl-201 SPECT). Specificity was significantly better for both Tl-201 SPECT (65%) and LDDE (62%) compared with collateral circulation (27%, P < .001 vs Tl-201 SPECT and LDDE). Furthermore, combined Tl-201 SPECT and LDDE data improved specificity (from 88% to 92%) and positive predictive power (from 75% to 78%) but not global accuracy. A direct relationship between the number of viable segments and global functional recovery after revascularization was found only in the case of Tl-201 SPECT (r = 0.48, P = .04). Conclusions. This study demonstrates that CC has a very low specificity in the evaluation of viability in collateral-dependent myocardium and that LDDE has a very low sensitivity, whereas Tl-201 SPECT is the most reliable method, particularly in akinetic segments, and optimally identifies patients who will mostly benefit from revascularization in terms of ventricular functional improvement. No additional advantages in terms of accuracy were found when Tl-201 SPECT and LDDE data were combined.

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ReviewThe coronary collateral circulation in living man

Abstract

Dis. Chest

Double internal mammary artery—myocardial implantation: Clinical evaluation of results in 150 patients

Circulation

Left internal mammary implant: Postoperative assessment

Circulation

Cine coronary arteriography

Mod. Concepts Cardiovas. Dis.

Cine coronary arteriography

Review
The coronary collateral circulation in living man