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Published on: May 14, 2013
Effect of revascularization of chronic total occlusion on tandem stenoses in a "donor" artery
Insights
Fractional flow reserve (FFR) can determine ischemia in coronary artery disease, even with collateral vessels. This aids in deciding revascularization strategies for complex cases.
Area of Science:
- Cardiology
- Interventional Cardiology
- Ischemia Assessment
Background:
- Coronary artery disease (CAD) outcomes depend on ischemia presence, severity, and extent.
- Evaluating ischemia in multivessel CAD to guide percutaneous coronary intervention (PCI) is challenging with noninvasive methods.
- A misconception exists that collateral circulation negates ischemia in chronic total occlusions (CTO).
Observation:
- An 82-year-old male presented with acute coronary syndrome.
- The patient had tandem stenoses in a "donor" artery and a chronic total occlusion of the right coronary artery.
- Assessing ischemia in CTO with collateral supply is critical for treatment decisions.
Findings:
- Fractional flow reserve (FFR) is a valuable tool for assessing myocardial ischemia.
- FFR can accurately determine the functional significance of coronary stenoses, even in the presence of collateral circulation.
- This case highlights the utility of FFR in guiding revascularization decisions for complex CTOs.
Implications:
- FFR can help overcome limitations of noninvasive ischemia evaluation in multivessel CAD and CTO.
- Accurate ischemia assessment with FFR can optimize PCI strategies and improve patient outcomes.
- Challenging the misconception about ischemia in collateralized CTOs is crucial for appropriate treatment planning.
Abstract:
The presence, severity, and extent of ischemia predict the outcome of coronary artery disease. Indeed the extent of myocardial ischemia and viability determines the value of revascularization in coronary stenosis after acute myocardial infarction. In multivessel coronary artery disease, noninvasive methods for the evaluation of ischemia are often inadequate to guide percutaneous coronary intervention. It is a common misperception that revascularization might not benefit a myocardial segment in the chronic total occlusion distribution when that segment is supplied by well-developed collateral vessels, because severe ischemia is unlikely to be present under these circumstances. An 82-year-old man presented with acute coronary syndrome, tandem stenoses in a "donor" artery, and a chronic total occlusion of the right coronary artery. We present a rationale for using fractional flow reserve to determine the existence of ischemia and to aid in deciding the best approach to the treatment of that ischemia.
