Excellent Collaterals Research Articles

When Third Time's a Charm: Successful Outcome after Third Orthotopic Heart Transplantation

IntroductionCardiac re-transplantation represents a small but growing proportion of total transplants being performed. Medical, ethical, moral and social dynamics continue to remain individualized and highly debated but more evolved with advancement in medicine for patients needing cardiac re-transplantation. We describe a case of a successful outcome in a patient requiring her third orthotopic heart transplant.CaseA 26 year old female with history of orthotopic heart transplant at age 11 for hypertrophic cardiomyopathy and subsequent re-transplantation for cardiac allograft vasculopathy (CAV) ten years later presented to our emergency room with cardiac arrest. Prior to the index hospitalization, the patient had an echocardiogram with a mildly reduced ejection fraction and an angiogram with chronic total occlusions of the right coronary artery and left circumflex artery with excellent collaterals and preserved cardiac output. Nuclear stress test showed no evidence of ischemia. Cardiac allograft vasculopathy prophylaxis with aspirin and pravastatin in addition to a triple regimen of immunosuppression of tacrolimus, sirolimus and mycophenolate mofetil were verified.The hospitalization was complicated by rapidly deteriorating biventricular function and three more episodes of cardiac arrest ultimately requiring extracorporeal membrane oxygenation (ECMO). Fortunately, the patient had negative HLAs with 0% CPRA and preserved end organ function. The selection committee thoughtfully considered her history of intermittent social marijuana use, active COVID 19 precautions in the hospital and a third sternotomy at such a young age, with likely need of possible 4th heart transplant in the future, but ultimately approved the patient for listing. Despite being Status 1, the patient had near daily loss of pulsatility for greater than 10-15 minutes which made us consider the possibility of total artificial heart. Fortunately, the patient received a local heart due to the COVID travel restrictions with total ischemic time of 98 minutes. She was induced with basiliximab and had negative retrospective and prospective crossmatches. There were no intra-op complications and post-op the patient had mild RV dysfunction requiring 4 days of inotropes. Patient was successfully discharged 9 days following her third OHT.ConclusionPatients undergoing re-transplantation have overall poorer outcomes than those undergoing primary transplantation. Several factors influence these outcomes including timing from prior transplant, previous sternotomy, sensitization status, and renal dysfunction. With advances in medicine and pediatric patients living well into adulthood, there will be more patients requiring re-transplantation. As these trends emerge, individualized patient selection remains the key factor to improved outcomes. Our case presents an otherwise healthy young woman with graft failure without evidence of sensitization who underwent a successful third transplantation.

Relevance of Collaterals for the Success of Neuroprotective Therapies in Acute Ischemic Stroke: Insights from the Randomized URICO-ICTUS Trial

Background: Collateral circulation may modify the effect of neuroprotective therapies. We report a post hoc analysis of the URICO-ICTUS trial (NCT00860366) assessing the modifying treatment effect of pretreatment collaterals on clinical and radiological outcomes in patients with large-vessel acute ischemic stroke receiving uric acid therapy or placebo. Methods: URICO-ICTUS was a randomized clinical trial where 411 alteplase-treated patients also received uric acid 1,000 mg (n = 211) or placebo (n = 200) before the end of alteplase infusion. Herein, we included a nested study of 84 patients (placebo = 40, uric acid = 44) who had a pretreatment CT-angiography (CTA) showing a proximal arterial occlusion in the carotid territory. Excellent collaterals were defined as 100% collateral supply on pretreatment CTA. Regression models assessed the interaction between therapy (uric acid/placebo) and collaterals on the main outcome (ordinal modified Rankin Scale [mRS] shift at 90 days). Results: Overall, excellent collaterals were associated with improved outcome. There was a significant interaction between therapy and pretreatment collaterals (p interaction = 0.02) for the prediction of improved mRS shift. The largest treatment contrast in favor of uric acid was found in patients with excellent collaterals (adjusted OR 9.2; 95% CI 1.23–68.6; p = 0.03). Conclusions: Collectively, the study found that collaterals were associated with the neuroprotective effect of uric acid therapy highlighting the importance of assessing collateral status in neuroprotection trials.

Better Collaterals Are Independently Associated With Post-Thrombolysis Recanalization Before Thrombectomy.

Background and Purpose- In acute stroke patients with large vessel occlusion, the goal of intravenous thrombolysis (IVT) is to achieve early recanalization (ER). Apart from occlusion site and thrombus length, predictors of early post-IVT recanalization are poorly known. Better collaterals might also facilitate ER, for instance, by improving delivery of the thrombolytic agent to both ends of the thrombus. In this proof-of-concept study, we tested the hypothesis that good collaterals independently predict post-IVT recanalization before thrombectomy. Methods- Patients from the registries of 6 French stroke centers with the following criteria were included: (1) acute stroke with large vessel occlusion treated with IVT and referred for thrombectomy between May 2015 and March 2017; (2) pre-IVT brain magnetic resonance imaging, including diffusion-weighted imaging, T2*, MR angiography, and dynamic susceptibility contrast perfusion-weighted imaging; and (3) ER evaluated ≤3 hours from IVT start on either first angiographic run or noninvasive imaging. A collateral flow map derived from perfusion-weighted imaging source data was automatically generated, replicating a previously validated method. Thrombus length was measured on T2*-based susceptibility vessel sign. Results- Of 224 eligible patients, 37 (16%) experienced ER. ER occurred in 10 of 83 (12%), 17 of 116 (15%), and 10 of 25 (40%) patients with poor/moderate, good, and excellent collaterals, respectively. In multivariable analysis, better collaterals were independently associated with ER ( P=0.029), together with shorter thrombus ( P<0.001) and more distal occlusion site ( P=0.010). Conclusions- In our sample of patients with stroke imaged with perfusion-weighted imaging before IVT and intended for thrombectomy, better collaterals were independently associated with post-IVT recanalization, supporting our hypothesis. These findings strengthen the idea that advanced imaging may play a key role for personalized medicine in identifying patients with large vessel occlusion most likely to benefit from IVT in the thrombectomy era.

Abstract 160: Better Collaterals Are Independently Associated With Post-thrombolysis Recanalization Before Thrombectomy

Introduction: In acute stroke with large-vessel occlusion (LVO), the goal of intravenous thrombolysis (IVT) is to achieve early recanalization (ER). Over and above occlusion site and thrombus length, better collaterals might also facilitate ER, for instance by improving delivery of the thrombolytic agent to both ends of the thrombus. In this proof-of-concept study, we tested the hypothesis that good collaterals independently predict post-IVT recanalization before thrombectomy. Methods: Patients from the registries of 6 French stroke centres with the following criteria were included: (1) acute stroke with LVO treated with IVT and referred for thrombectomy between May 2015 and March 2017; (2) pre-IVT brain MRI, including diffusion weighted imaging, T2*, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI); and (3) ER evaluated ≤3hrs from IVT start on either first angiographic run or non-invasive imaging. A collateral flow map derived from PWI source data was automatically generated, replicating Kim et al’s previously validated method (Ann. Neurol., 2014). Thrombus length was measured on T2*-based susceptibility vessel sign. Results: Of 224 eligible patients, 37 (16%) experienced ER. ER occurred in 10/83 (12%), 17/116 (15%) and 10/25 (40%) patients with poor/moderate, good and excellent collaterals, respectively. In multivariable analysis, better collaterals were independently associated with ER ( P =0.029), together with shorter thrombus ( P &lt;0.001) and more distal occlusion site ( P =0.010). Conclusions: In our sample of stroke patients imaged with PWI before IVT and intended for thrombectomy, better collaterals were independently associated with post-IVT recanalization, supporting our hypothesis. These findings strengthen the idea that advanced imaging may play a key role for personalized medicine in the thrombectomy era by identifying LVO patients most likely to benefit from IVT.

Coronary artery dominance dependent collateral development in the human heart.

In obstructive coronary artery disease, coronary collateral arteries serve as alternative conduits for blood flow to the myocardial tissue supplied by the obstructed vessel(s). Therefore, they are a "natural coronary arterial bypass" to the region supplied by the obstructed vessels. This study aims to determine the influence of demographic and morphologic coronary arterial factors on coronary collateral development in coronary arterial obstruction. The study group was selected from the coronary angiographic records of 2029 consecutive patients (mean age: 59 ± 12 years). Coronary collaterals were graded from 0 to 3 based on the collateral connection between the donor and recipient arteries. The angiograms of the patients (n = 286) with total obstruction of the coronary arteries were selected for analysis. There were no significant association between patients' age and sex and the formation of excellent collaterals. However, the location of atherosclerotic lesion affected collateral development in the right coronary artery. In addition, the right coronary arterial dominant pattern significantly influenced the formation of excellent coronary collaterals. Coronary collateral arteries are better developed in right dominant pattern. It may be concluded that coronary arterial morphological pattern influences coronary collateral artery development.

Abstract WP33: Reperfusion Therapy in Carotid Artery Occlusion with Collaterals Through the Circle of Willis

Introduction: In large artery occlusion, endovascular treatment shows better recanalization rate than intravenous tPA alone. In reperfusion therapy, excellent collaterals through the circle of Willis has better prognosis. We hypothesized that intravenous tPA only is comparable to endovascular therapy in carotid occlusion with patent ‘T’. Methods: Between January 2010 and December 2015, in acute stroke patients who had received a reperfusion therapy, carotid artery occlusion with good collateral via the circle of Willis were selected. In all patients, non-contrast CT and CT angiography were conducted before reperfusion therapy and at 24 (+/-6) hours and/or clinical worsening. Stroke severity was assessed with NIHSS at baseline and discharge. The prognosis of reperfusion therapy was assessed by modified Rankin Scales at 3 months. Results: In 529 patients treated by reperfusion therapy, 29 patients (5.5%, male 21, median age 76) had internal carotid artery occlusion with patent ‘T’. In tPA alone (24 patients, 82.8%), baseline NIHSS were non-significantly lower than in endovascular treatment (10 vs 15, p=0.224). Recurrent stroke, which was confirmed with follow up angiography, was developed in 8 of tPA alone. In endovascular treatment, one had a distal embolization. In 22 patients who could be assessed by MRS, 10 patients (45.5%, tPA in 9, IA in 1) had good mRS and 6 patients (27.3%) were expired. Conclusions: Carotid occlusion with good collaterals via the circle of Willis was uncommon. tPA alone resulted in recurrent stroke with clinical worsening. Endovascular treatment may be better option in carotid occlusion with patent ‘T’.

Značaj retrogradnog koronarnog protoka nakon primarne PCI

Coronary collateral arteries are alternative conduits for blood flow in obstructive coronary heart disease (CAD). Collateral circulation is important in preserving ventricular function in coronary artery disease with total occlusion. Still, during exercise these collaterals are often limited in their functional reserve. This case demonstrates unusual presentation of stress echocardiography (SEcho) and coronary flow reserve (CFR) in the patient after primary percutaneous coronary intervention (pPCI). Due to the limited area of myocardial ischemia provoked with exercise and retrograde coronary flow with the value of CFR correspondent to excellent collaterals, the patient was left on medical therapy, even thou the repeated coronary angiography showed complete in-stent occlusion of the proximal to middle LAD with well-developed collaterals.

An excellent collateralization between left internal mammary artery to left external iliac artery

An excellent collateralization between left internal mammary artery to left external iliac artery

PP-325 An Excellent Collateralization between Left Internal Mammary Artery to External Iliac Artery

Left internal mammarian arter ( LIMA )is commonly used in coronary by pass operations. Patient with severe atherosclerosis peripheric artery disease could be coexistence with coronary artery disease. In some patients LIMA may provide lower extremity blood supply through to collateral brunchs.

Abstract 4: Excellent Collaterals in STAR: Minimal Infarct Core Trumps the Degree of Hypoperfusion

Background: Collateral grade on DSA before acute endovascular therapy of stroke predicts revascularization. Excellent collaterals were a potent predictor of good clinical outcomes at 90 days after treatment in Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR). We studied whether excellent collaterals could be detected with either CT or MR perfusion imaging acquired immediately before treatment. Methods: Independent angio and CT/MRI core labs analyzed baseline DSA ASITN/SIR collateral grade and CT/MR perfusion imaging volumes (equivalent definitions of infarct core and Tmax &gt; 4, 6, 8, 10, 12, 14 s). Hypoperfusion was defined as Tmax &gt; 6s, with Tmax hypoperfusion intensity ratios of 10/6 and 14/6, and target and malignant profiles based on DEFUSE-2. Excellent collateral grade (3-4) was analyzed by pretreatment CT/MRI patterns. Results: 64 of 202 cases in STAR (mean age 67.9 ± 13.1 years; 53% women; median baseline NIHSS 15 (8-25)) had CT/MR perfusion volumes and ASITN/SIR collateral grade analyzed. Distribution of collateral grade (0, n=2; 1, n=31; 2, n=14; 3, n=15; 4, n=2) was similar to the entire STAR population. Excellent collaterals were unrelated to age and gender, with a trend towards lower NIHSS (OR 0.9, p=0.12). Excellent collaterals in 17/64 (27%) demonstrated very small core volumes (0 cc, n=8; 1-25 cc, n=8; &gt; 25 cc, n=1) compared to other cases. Similarly, clinical-core mismatch (defined as baseline NIHSS ≥8-16 and core ≤ 25 cc; baseline NIHSS ≥17 and ≤ 50 cc) was noted in 16/17 (94%). The extent of hypoperfusion (Tmax &gt; 6s) and degrees of hypoperfusion (Tmax 4-14, 10/6, and 14/6) were not related to the presence of excellent collaterals. Target mismatch (n=53/64, 83%) showed an OR 4.32 (p=0.18) for excellent collaterals and no malignant profiles were associated with grade 3-4. Conclusions: CT/MR perfusion patterns prior to endovascular therapy are associated with excellent collaterals, evident as very small infarct core, target mismatch, and clinical-core mismatch. The degree of Tmax hypoperfusion severity alone cannot be used to identify presence of excellent collaterals.

Role of Statin in Atrial Fibrillation-Related Stroke: An Angiographic Study for Collateral Flow

Background: Currently, intensive lipid lowering is recommended in patients with atherosclerotic ischemic stroke or transient ischemic attack. However, the role of statin in cardioembolic stroke is unclear. We investigated the association of statin with pretreatment collateral status in cardioembolic stroke. Methods: A collaborative study from two stroke centers in distinct geographic regions included consecutive patients with acute middle cerebral artery (MCA) infarction due to atrial fibrillation (AF) who underwent cerebral angiography. The relationship between pretreatment collateral grade and the use/dose of statin at stroke onset was assessed. The angiographic collateral grade was evaluated according to the ASITN/SIR Collateral Flow Grading System. Results: Ninety-eight patients (76 statin-naïve, 22 statin users) were included. Compared with statin-naïve patients, statin users were older and more frequently had hypertension, hyperlipidemia and coronary heart disease. Excellent collaterals (grade 3-4) were more frequently observed in statin users (11 patients, 50%) than in statin-naïve patients (21 patients, 27.6%; p = 0.049). The use of atorvastatin 10 mg equivalent or higher doses of statin was associated with excellent collaterals (p for trend = 0.025). In multiple regression analysis, prestroke statin use was independently associated with excellent collaterals (odds ratio, 7.841; 95% confidence interval, CI, 1.96-31.363; p = 0.004). Conclusions: Premorbid use of statin in AF patients is associated with excellent collateral flow. Although most statin trials excluded patients with cardioembolic stroke, our data suggests the possibility that statin may be beneficial in AF-related stroke.

Operative treatment of chronic mesenteric ischemia

Chronic ischemic lesions of the splanchnic organs are often underestimated and underdiagnosed. The etiology, therapy and prognosis of acute mesenteric ischemia can be distinguished from chronic splanchnic ischemia. Progression of underlying atherosclerosis and the polymorbidity of the aging population results in an increased prevalence of chronic mesenteric ischemia, and occlusions of splanchnic arteries are diagnosed more frequently. Due to excellent collateralization, diffuse stenotic processes may remain asymptomatic for a long time. Computed tomography angiography with 3D reconstruction is the preferred diagnostic tool, while diagnostic angiography is more often utilized in combination with endovascular treatment (catheter-derived infusion therapy, lysis, percutaneous transluminal angioplasty, stent). Duplex sonography reveals relevant insights into the hemodynamic severity of the lesion. However, the diagnostic accuracy of Duplex sonograpy is often restricted due to bowel gas and operator dependency.In this article the operative treatment of chronic intestinal ischemia is discussed and a classification for treatment stratification is proposed.

Intestinal ischemia

Ischemic changes of the abdominal organs are crucial since they develop slowly and are therefore often diagnosed at a late stage. Due to this general aspect, mortality from this disease could not be significantly reduced over the last decade. One of the main causes of these high mortality rates is the insufficient integration of the overall clinical picture into the diagnostic work-up. Acute mesenteric ischemia should be differentiated from chronic visceral ischemia. Acute intestinal ischemia is a vascular emergency with a mortality rate of 60-80%. The incidence of chronic visceral vascular disorders accounts for approximately 1-2% of all abdominal conditions and has to be differentiated from the acute form, since intestinal ischemia has a progressive nature and usually is related to general atherosclerotic disease. Therefore, this condition is associated with an increase of arteriosclerotic-related multimorbidity in an increasingly elderly population. Due to excellent collateralization, extensive chronic occlusion processes affecting the visceral arteries can be asymptomatically treated on a long-term basis.

Collateral Flow Predicts Response to Endovascular Therapy for Acute Ischemic Stroke

Collaterals sustain the penumbra before recanalization and offset infarct growth, yet the influence of baseline collateral flow on recanalization after endovascular therapy remains relatively unexplored. We analyzed consecutive patients who received endovascular therapy for acute cerebral ischemia from 2 distinct study populations. We assessed the relationship between pretreatment collateral grade and vascular recanalization (Thrombolysis In Myocardial Ischemia [TIMI] scale). In addition, we assessed infarct growth on serial MRI. A total of 222 patients was included, 138 from the United States and 84 from South Korea. Complete revascularization occurred in 14.1% (11 of 78) patients with poor pretreatment collateral grades, whereas it was observed in 25.2% (26 of 103) patients with good collaterals and 41.5% (17 of 41) patients with excellent collaterals (P<0.001). This relationship was consistently observed in both study populations, although the mode of endovascular therapy was different between them. After adjustment for other factors, including mode of endovascular therapy, prior use of intravenous tissue plasminogen activator, and site of occlusion, pretreatment collateral grade was independently associated with recanalization. When revascularization was achieved, greater infarct growth occurred in patients with poor collaterals than in those with good collaterals (P=0.012). Our data indicate that angiographic collateral grade determines the recanalization rate after endovascular revascularization therapy. When therapeutic revascularization was achieved, beneficial effects were not observed in patients with poor collaterals. Angiographic collateral grade may therefore help guide treatment decision-making in acute cerebral ischemia.

Chronic intestinal ischemia

Ischemic lesions of the splanchnic organs are characterized by an insidious course and therefore are often underestimated. They can result in dramatic courses of disease which even in the last decade still results in a mortality of up to 90%. The reasons for this depressing situation are various but mainly due to insufficient consideration of the symptoms and late therapy due to delayed diagnosis.The incidence of chronic splanchnic ischemia is approximately 1-2% of all abdominal diseases. In contrast to acute intestinal ischemia the course is progressive, caused by progression of the underlying atherosclerosis and polymorbidity in this aging society. On the one hand occlusions of splanchnic arteries are diagnosed more often and on the other hand the incidence has increased due to the rising number of therapy-linked vascular catheter maneuvers. Due to excellent collateralization, diffuse stenotic processes can maintain asymptomatic for a long time. Duplex sonography should be performed as this technique reveals relevant insights into the hemodynamic severity of lesions.

On the Relationship between Changes in the Deep Veins Evaluated by Duplex Sonography and the Postthrombotic Syndrome 12 Years after Deep Vein Thrombosis

In a prospective study we performed color duplex ultrasonography to evaluate patency and valvular function of previous thrombosed veins 12 years after the acute thrombosis. Normal clinical findings were found in 64% of the patients, mild postthrombotic skin changes in 28%, and marked trophic changes in 5%; only 1 venous ulcer occurred. In 39 patients, 114 initially thrombosed vein segments were evaluated. Thirty-seven of 72 proximal segments were completely recanalized (23 with valvular incompetence) and 21 segments exhibited partial recanalization (19 with valvular incompetence). Superficial femoral vein segments were completely occluded in 19%, however, excellent collateralization was provided via the deep femoral vein. Thromboses of the posterior tibial vein demonstrated a high rate of recanalization with development of valvular incompetence in 52%. Whereas obstruction and valvular incompetence as single factors led to a postthrombotic leg in 8.5% and 33%, respectively, the most frequent cause for the development of the postthrombotic syndrome was the combination of reflux plus obstruction in the deep veins (50%). Compression therapy with elastic compression stockings is recommended for at least 5 years after the acute thrombosis.

Midaortic syndrome and hypertension in childhood

Midaortic syndrome is a form of fibromuscular hyperplasia that involves the abdominal aorta including the renal and visceral branches. Symptomatology depends on the degree and location of vessel narrowing. This report updates the authors' experience and details 17 operative cases, the largest reported series. Seventeen of the 45 patients who have been operated on for severe renovascular hypertension have had this syndrome. Ages have ranged from 5 months to 15 years (average, 9.7 years). Signs and symptoms have included various manifestations of malignant hypertension, congestive heart failure, oliguric renal failure, and claudication. Intestinal angina has not been noted despite celiac and/or superior mesenteric arterial involvement. Although balloon angioplasty was performed in two patients, lasting results were not achieved. One primary nephrectomy was performed. The other 16 patients had vascular reconstructions including aortoaortic bypass grafting (n = 12), with bilateral renal artery bypasses (n = 9) or unilateral renal bypass (n = 3) or bilateral renal bypass alone (n = 4). The majority had associated visceral artery narrowing, but excellent collaterals have been present so no visceral reconstructions have been required. All renal artery bypasses have been with reinforced saphenous vein. Results: In the average follow-up period of 48 months, 12 of the 17 patients have been cured of hypertension, and the other five have improved. Claudication, congestive failure, and renal failure have been alleviated. Thus far, reinforcement of the saphenous vein grafts has prevented aneurysmal degeneration and graft loss. Conclusion: These results indicate that aggressive single-stage reconstruction is the best approach for these children.