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      Coronary chronic total occlusion intervention: A pathophysiological perspective

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          Abstract

          Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is the last frontier in coronary intervention. PCI of CTO carries multiple advantages, such as significant improvement in symptoms, improvement in abnormal wall motion and left ventricular function and, possibly, increased long-term survival. As of today the procedural success is markedly improved because of technical innovations and is limited to highly experienced operators. To enhance the overall success rate from a worldwide perspective, a thorough understanding of its pathophysiology is critical to further development of newer techniques and technologies. In this review, the author outlines in-depth the evidence that underpins our understanding of CTO pathophysiology and its insight into CTO intervention that incorporates various steps and techniques to cross the lesion.

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          Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects.

          K. Peter Rentrop, Marc Cohen, Heiner Blanke … (1985)
          Transluminal coronary angioplasty can serve as a model for controlled coronary artery occlusion and reperfusion which enables assessment of short-term changes in collateral vessel filling in patients with severe atherosclerotic coronary artery disease. In 16 patients with isolated left anterior descending or right coronary artery disease (greater than or equal to 75% stenosis) and normal left ventricular function, collateral filling to the artery being dilated was visualized by contrast injection into the contralateral artery using a second arterial catheter. During balloon inflation, contralateral dye injection was performed as soon as the patient developed angina or ST-T changes or at 90 seconds in those patients without symptoms or signs of ischemia. Grades of collateral filling from the contralateral vessel were: 0 = none; 1 = filling of side branches of the artery to be dilated via collateral channels without visualization of the epicardial segment; 2 = partial filling of the epicardial segment via collateral channels; 3 = complete filling of the epicardial segment of the artery being dilated via collateral channels. At baseline angiography, nine patients had grade 0 collateral filling, seven had grade 1 and none had grade 2 or 3. During coronary occlusion by balloon inflation, collateral filling improved by one grade in eight patients, two grades in five patients, three grades in two patients and remained the same in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)
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            Collateral circulation

            Wolfgang Schaper (2009)
            Following an arterial occlusion outward remodeling of pre-existent inter-connecting arterioles occurs by proliferation of vascular smooth muscle and endothelial cells. This is initiated by deformation of the endothelial cells through increased pulsatile fluid shear stress (FSS) caused by the steep pressure gradient between the high pre-occlusive and the very low post-occlusive pressure regions that are interconnected by collateral vessels. Shear stress leads to the activation and expression of all NOS isoforms and NO production, followed by endothelial VEGF secretion, which induces MCP-1 synthesis in endothelium and in the smooth muscle of the media. This leads to attraction and activation of monocytes and T-cells into the adventitial space (peripheral collateral vessels) or attachment of these cells to the endothelium (coronary collaterals). Mononuclear cells produce proteases and growth factors to digest the extra-cellular scaffold and allow motility and provide space for the new cells. They also produce NO from iNOS, which is essential for arteriogenesis. The bulk of new tissue production is carried by the smooth muscles of the media, which transform their phenotype from a contractile into a synthetic and proliferative one. Important roles are played by actin binding proteins like ABRA, cofilin, and thymosin beta 4 which determine actin polymerization and maturation. Integrins and connexins are markedly up-regulated. A key role in this concerted action which leads to a 2-to-20 fold increase in vascular diameter, depending on species size (mouse versus human) are the transcription factors AP-1, egr-1, carp, ets, by the Rho pathway and by the Mitogen Activated Kinases ERK-1 and -2. In spite of the enormous increase in tissue mass (up to 50-fold) the degree of functional restoration of blood flow capacity is incomplete and ends at 30% of maximal conductance (coronary) and 40% in the vascular periphery. The process of arteriogenesis can be drastically stimulated by increases in FSS (arterio-venous fistulas) and can be completely blocked by inhibition of NO production, by pharmacological blockade of VEGF-A and by the inhibition of the Rho-pathway. Pharmacological stimulation of arteriogenesis, important for the treatment of arterial occlusive diseases, seems feasible with NO donors.
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              A percutaneous treatment algorithm for crossing coronary chronic total occlusions.

              Emmanouil S Brilakis, J. Aaron Grantham, Stéphane Rinfret … (2012)
              Coronary chronic total occlusions (CTOs) are frequently identified during coronary angiography and remain the most challenging lesion group to treat. Patients with CTOs are frequently left unrevascularized due to perceptions of high failure rates and technical complexity even if they have symptoms of coronary disease or ischemia. In this review, the authors describe a North American contemporary approach for percutaneous coronary interventions for CTO. Two guide catheters are placed to facilitate seamless transition between antegrade wire-based, antegrade dissection re-entry-based, and retrograde (wire or dissection re-entry) techniques, the "hybrid" interventional strategy. After dual coronary injection is performed, 4 angiographic parameters are assessed: 1) clear understanding of location of the proximal cap using angiography or intravascular ultrasonography; 2) lesion length; 3) presence of branches, as well as size and quality of the target vessel at the distal cap; and 4) suitability of collaterals for retrograde techniques. On the basis of these 4 characteristics, an initial strategy and rank order hierarchy for technical approaches is established. Radiation exposure, contrast utilization, and procedure time are monitored throughout the procedure, and thresholds are established for intraprocedural strategy conversion to maximize safety, efficiency, and effectiveness.
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                Author and article information

                Contributors
                Debabrata Dash
                Journal
                Journal ID (nlm-ta): Indian Heart J
                Journal ID (iso-abbrev): Indian Heart J
                Title: Indian Heart Journal
                Publisher: Elsevier
                ISSN (Print): 0019-4832
                Publication date (Print): Jul-Aug 2018
                Publication date (Electronic): 10 January 2018
                Volume: 70
                Issue: 4
                Pages: 548-555
                Affiliations
                [a ]Thumbay Hospital, Ajman, United Arab Emirates
                [b ]Beijing Tiantan Hospital, Beijing, China
                Author notes
                [* ]Corresponding author. Present address: Thumbay Hospital, P.O Box 4184, Ajman, United Arab Emirates. dr.debabrata@ 123456thumbayhospital.ae
                Article
                Publisher ID: S0019-4832(17)30303-6
                DOI: 10.1016/j.ihj.2018.01.021
                PMC ID: 6116719
                PubMed ID: 30170652
                SO-VID: f29e4c6e-bf77-4ce2-8940-075902bb17c4
                Copyright © © 2018 Published by Elsevier B.V. on behalf of Cardiological Society of India.
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 3 May 2017
                Date accepted : 10 January 2018
                Categories
                Subject: Review Article

                Keywords: cto, chronic total occlusion,pci, percutaneous coronary intervention,mdct, multiple detector computed tomography,ivus, intravascular ultrasound,cart, controlled antegrade and retrograde subintimal tracking,chronic total occlusion,pathophysiology,percutaneous coronary intervention
                Data availability:
                Keywords: cto, chronic total occlusion, pci, percutaneous coronary intervention, mdct, multiple detector computed tomography, ivus, intravascular ultrasound, cart, controlled antegrade and retrograde subintimal tracking, chronic total occlusion, pathophysiology, percutaneous coronary intervention

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