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The haemodynamic effects of collateral donation to a chronic total occlusion: Implications for patient management
Andrew Ladwiniec1, Angela Hoye1
1Department of Academic Cardiology, Daisy Building, Castle Hill Hospital, Castle Road, Hull HU16 5JQ, UK.
Insights
Fractional Flow Reserve (FFR) may be unreliable for guiding revascularization in chronic total occlusions (CTOs) due to collateral flow effects. Further research is needed to understand how CTO revascularization impacts donor vessel physiology and impacts treatment strategies.
Area of Science:
- Cardiovascular physiology
- Interventional cardiology
- Coronary artery disease
Background:
- Fractional Flow Reserve (FFR) is standard for guiding multi-vessel revascularization.
- Chronic total occlusions (CTOs) often coexist with multi-vessel disease.
- Collateral circulation supplies myocardium distal to CTOs from donor arteries.
Purpose of the Study:
- To review literature on the hemodynamic effects of collateral donation on donor vessel FFR in CTOs.
- To summarize current knowledge on how CTO revascularization impacts collateral flow and donor vessel physiology.
- To identify areas for future research to inform clinical practice.
Main Methods:
- Literature review of existing studies.
- Synthesis of current understanding of coronary physiology.
- Identification of knowledge gaps regarding CTOs and collateral circulation.
Main Results:
- Collateral donation may alter donor vessel hemodynamics, potentially compromising FFR reliability.
- Revascularization of CTOs could impact donor vessel FFR, affecting ischemia prediction.
- Limited research directly addresses the FFR implications of collateral flow in CTOs.
Conclusions:
- The hemodynamic influence of collateral flow on donor vessel FFR in CTOs requires further investigation.
- Optimal revascularization strategies in multi-vessel disease may be affected by CTO presence.
- Additional studies are crucial to clarify the impact of CTO revascularization on coronary physiology and guide treatment decisions.
Abstract:
Physiological lesion assessment in the form of Fractional Flow Reserve (FFR) is now well established for the purpose of guiding multi-vessel revascularization. Chronic total coronary occlusions are frequently associated with multi-vessel disease and the collateral dependent myocardium distal to the occlusion is often supplied by a collateral supply from another epicardial coronary artery. The haemodynamic effect of collateral donation upon collateral donor vessel flow may have important implications for the vessel's FFR; rendering it unreliable at predicting ischaemia should the CTO be revascularized. As a consequence, in the setting of multi-vessel disease, optimal revascularization strategy might be altered. There is a paucity of work in the medical literature directly examining this phenomenon. We endeavoured to review the existing literature related to it, to summarise from current knowledge of coronary physiology what is known about the potential effects of CTO revascularization on both collateral flow and collateral donor vessel physiology, and to highlight where further studies might inform practice.
