Pathways Of Collateral Circulation Research Articles

Analysis of characteristics of collateral circulation pathways in dizziness patients caused by severe bilateral vertebral artery stenosis/occlusion

The clinical data of 47 patients [41 males, 6 females, aged (62±7) years] treated at the Department of Neurology of the Sixth Medical Center of PLA General Hospital from October 2018 to October 2020 who were diagnosed with severe bilateral vertebral artery stenosis/occlusion through Digital Subtraction Angiography (DSA) were retrospectively collected, and the characteristics of the compensatory pathways of collateral circulation were determined. Results showed that there were 8 intracranial and extracranial compensatory pathways, with posterior communicating artery as the major type (21 cases) for intracranial ones and deep carotid artery as the major type (16 cases) for extracranial ones. As the establishment of the compensatory pathway is closely related to the lesion site, DSA assessment for patients with severe bilateral vertebral artery stenosis/occlusion is helpful for clinicians to make judgement on prognosis of patients and choose individualized treatment plans.

Collateral circulation compensation mode in patients with severe bilateral internal carotid artery stenosis/occlusion

Objective: To investigate the correlation between collateral flow compensation mode and interventional treatment decision in patients with severe bilateral internal carotid artery stenosis/occlusion. Methods: According to the location of internal carotid artery lesions, patients with severe stenosis/occlusion of bilateral internal carotid artery were selected at the Second Affiliated Hospital, Qiqihar Medical University and the Sixth Medical Center of PLA General Hospital from May 2017 to June 2020. Results: A total of 42 patients were finally enrolled and divided into 4 types, including 34 males and 8 females with median age 61±8(48-82)years. The collateral circulation pathways manifested as following modes: anterior communicating artery collateral, posterior communicating artery collateral, ophthalmic artery collateral, posterior cerebral middle cerebral artery pial anastomosis collateral, posterior choroidal artery anterior choroidal artery collateral, external carotid internal carotid artery C4 segment collateral, pericallosal artery anastomosis collateral, dural and pial collateral and neovascularization. Type Ⅰ severe stenosis/occlusion of C1 segment was found in 20 cases (47.6%). There were 5 cases (11.9%) of type Ⅱ severe stenosis/occlusion from C2 to C6 prior to ophthalmic artery branch. Type Ⅲ severe stenosis/occlusion occurred in 2 cases (4.8%) after the split of ophthalmic artery. Type Ⅳ was mixed type in 15 cases (35.7%). Conclusions: The compensatory pathway of collateral circulation is closely related to the lesion location. To explore the compensatory pattern of collateral circulation is helpful for clinicians to accurately analyze the lesion characteristics and guide individualized interventional therapy.

Four collateral circulation pathways were observed after common carotid artery occlusion

BackgroundCommon carotid artery (CCA) occlusion (CCAO) is a rare condition. Owing to collateral circulation, ipsilateral internal carotid artery (ICA) and external carotid artery (ECA) are often patent.MethodsThis study included 16 patients with unilateral CCAO and patent ipsilateral ICA and ECA. The pathways which supplied ICA were investigated by digital subtraction angiography (DSA), transcranial Doppler (TCD), magnetic resonance angiography (MRA) and computed tomography angiography (CTA).ResultsIn all 16 patients, TCD found antegrade blood flow in ipsilateral ICA, which was supplied by retrograde blood flow in ipsilateral ECA through carotid bifurcation. We call this phenomenon “ICA steal”. DSA and CTA discovered four pathways of ICA steal, including 1) ipsilateral vertebral artery – occipital artery – ECA – ICA, 2) ipsilateral thyrocervical trunk or costocervical trunk – ascending cervical artery or deep cervical artery – occipital artery – ECA – ICA, 3) contralateral ECA – contralateral superior thyroid artery – ipsilateral superior thyroid artery – ipsilateral ECA – ICA, and 4) ipsilateral thyrocervical trunk – inferior thyroid artery – superior thyroid artery – ECA – ICA.ConclusionsICA is possible to be patent and supplied by several collateral circulation pathways after CCAO.

Arterial collateral circulation pathways in patients with aortoiliac occlusive disease.

Objectives Aortoiliac occlusive disease is a leading cause of morbidity and mortality worldwide. Patients typically present with intermittent claudication or critical limb ischemia but the majority of them remain asymptomatic. Collateral arterial pathways restore the arterial blood supply distal to the lesions. The objective of this study is the description of collateral pathways’ patterns of aortoiliac occlusive disease. Methods Records from the Department of Vascular Surgery of University General Hospital of Alexandroupolis were retrospectively searched from March 2016 to August 2018 for patients suffering from aortoiliac occlusive disease. Results Thirty-three patients (24 males, 9 females) with a mean age of 64.2 ± 11.8 years were included in this study. Twenty-two patients had diabetes mellitus, 25 hypertension, and 16 dyslipidemia. Twenty-two were active smokers. Seventeen patients suffered from intermittent claudication and 16 patients presented with critical limb ischemia. Seven patients had TASC-II B lesions, 10 TASC-II C lesions, and 16 patients had TASC-II D lesions. Systemic collateral pathways were dominant in 17 patients, whereas visceral pathways were prominent in 16 patients. While 62.5% of patients having lesions in the abdominal aorta presented systemic pathways, the lesions located only in the iliac arteries followed visceral patterns or systematic patterns equally. Conclusions Collateral anastomotic networks provide blood supply to regions distal to aortoiliac occlusive lesions. Their pattern is defined mainly by the location of the lesion and does not seem to associate with comorbid factors or the extent of the lesion. Failure to recognize these networks during surgery could lead to limb threatening situations.

The clinical presentation and collateral pathway development of congenital absence of the internal carotid artery

ObjectiveThe objective of this study was to investigate the clinical presentation, risks, and collateral pathway development of the congenital absence of the internal carotid artery (ICA). MethodsSixty-four patients (10 new patients and 54 patients from the relevant literature) were studied. Data on demographic, clinical, and radiologic features were collected, followed by an analysis of the risks associated with ICA agenesis. ResultsThere were 31 male and 33 female patients whose ages ranged from 5 months to 75 years, with a mean age of 31.1 years. The range of clinical symptoms recorded included transient ischemic attack (17 patients), subarachnoid hemorrhage (12 patients), developmental delay (13 patients), asymptomatic (8 patients), and other symptoms (15 patients). All 64 patients presented with absence of unilateral or bilateral ICAs, as measured by cervical computed tomography angiography or magnetic resonance angiography. The carotid canal was absent in all patients on computed tomography of the base of the skull, and abnormal development of collateral circulation pathways was observed. Five patients presented with basilar artery dilation on angiography. Aneurysms were observed in the angiography results from 16 patients. Ten patients presented with variations in the ophthalmic artery origin (the ophthalmic artery originated from the ipsilateral middle meningeal artery in six patients and from the ipsilateral middle cerebral artery in four patients). ConclusionsFrom analysis of our 10 cases of ICA agenesis and our review of the relevant literature, we conclude that young patients with ICA agenesis may present with developmental delay, subarachnoid hemorrhage, or other developmental abnormalities, whereas older patients most commonly present with transient neurologic events. Complications of carotid agenesis are related to specific anatomic subtypes and the resulting collateral circulation development.

Nonvisualization of the Internal Carotid Artery on Computed Tomography Angiography: Discussion of Two Cases with Review of Literature.

Nonvisualization of the internal carotid artery (ICA) on cross-sectional imaging studies can be due to congenital (dysgenesis of the ICA) or acquired (complete occlusion of ICA) causes. We report two cases, one with absent carotid canal on bone window setting of computed tomography (CT) suggestive of congenital cause and the other with normal carotid canal, suggesting acquired cause. Development of aortic arches with six pathways of collateral circulation in brain is also discussed.

Experimental study of hemodynamics in the Circle of Willis.

BackgroundThe Circle of Willis (CoW) is an important collateral pathway of the cerebral blood flow. An experimental study of the cerebral blood flow (CBF) distribution in different anatomical variations may help to a better understanding of the collateral mechanism of the CoW.MethodsAn in-vitro test rig was developed to simulate the physiological cerebral blood flow in the CoW. Ten anatomical variations were considered in this study, include a set of different degrees of stenosis in L-ICA and L-ICA occlusion coexist with common anatomical variations. Volume flow rates of efferent arteries and pressure signals at the end of communicating arteries of each case were recorded. Physiological pressure waveforms were applied as inlet boundary condition.ResultsIn the development of L-ICA stenosis, the total CBF decreases with the increase of stenosis degree. The blood supply of ipsilateral middle cerebral artery (MCA) was affected most by the stenosis of L-ICA. Anterior communicating artery (ACoA) and ipsilateral posterior communicating artery (PCoA) function as important collateral pathways of cerebral collateral circulation when unilateral stenosis occurred. The blood supply of anterior cerebral circulation was compensated by the posterior cerebral circulation through ipsilateral PCoA when L-ICA stenosis degree is greater than 40% and the affected side was compensated immediately by the unaffected side through ACoA. Blood flow of the anterior circulation and the total CBF reached the minimum among all cases studied when L-ICA occlusion coexist with the absence of PCoA.ConclusionThe results demonstrated the flow distribution patterns of the CoW under anatomical variations and clarified the collateral mechanism of the CoW. The flow ACoA is the most sensitive indexes to the morphology change of ipsilateral ICA. The relative independence of the circulation in anterior and posterior sections of the CoW is not broken and the function of ipsilateral PCoA is not activated until a severe stenosis of unilateral ICA occurs. PCoA is the most important collateral pathway of the collateral circulation and the missing of PCoA has the highest risk of stroke when the ipsilateral ICA has severe stenosis. These findings may provide the basis for future therapeutic and diagnosis applications.

Complete Avulsion of Brachial Plexus with Associated Vascular Trauma

Vascular trauma associated with brachial plexus injury affects the selection of reconstructive procedures. Often, there is a paucity of appropriate recipient vessels with adequate blood flow for functioning free muscle transfer. The presence of associated vascular injuries of the subclavian or axillary artery is considered a contraindication to the double free muscle technique. The authors hypothesized that vascular repair of subclavian or axillary artery trauma might not be necessary for successful reconstruction using the double free muscle technique, provided that the recipient arteries for functioning free muscle transfer (e.g., thoracoacromial and thoracodorsal arteries) are found to be patent on preoperative angiography. The authors investigated the pathway of collateral circulation and potential recipient vessels for functioning free muscle transfer reconstruction in 20 brachial plexus injury patients associated with subclavian or axillary artery trauma using multidetector-row computed tomographic angiography. Based on these findings, the authors restored upper extremity function using the double free muscle technique without surgical repair of the injury to the major vessel in three patients. The suprascapular artery was the major stem artery for collateral circulation, and the circumflex scapular and subscapular arteries were major reentry arteries. The authors successfully used the thoracoacromial and thoracodorsal arteries as the recipient vessels for functioning free muscle transfers in the double free muscle technique. The preliminary functional outcomes of all three cases were satisfactory. This study demonstrates the feasibility of double free muscle technique reconstruction in brachial plexus injury patients, without actual vascular repair for the associated subclavian or axillary artery trauma. Therapeutic, IV.

Chronisch-progrediente Durchblutungsstörungen der Darmarterien – kompakte Kurzübersicht aus gefäßchirurgischer Perspektive

Intestinal ischaemia is quite rare among the cardiovascular diseases. However, it is increasingly diagnosed. The aim of this selective but representative short overview is to assess the impact of intestinal ischaemia in vascular and visceral medicine from a vascularsurgical perspective. A literature search and selection in relevant online services of the medical scientific literature was performed, in particular, of the last decade on the competent management of intestinal ischaemia combined with the clinical expertise obtained in daily vascular surgical practice including didactically prepared demonstrable cases / case reports related to typical / specific clinical problems and situations. Although the superior mesenteric artery (SMA) is most frequently responsible for the clinical presentation, usually 2 or 3 major arterial trunks are involved for a relevant clinical symptomatology. These disorders of the intestinal circulation are most frequently caused by progressive atherosclerotic occlusive disease. In chronic progressive disease, the visceral arteries show the ability to enlarge typical collateral circulation pathways, which may not always lead to a complete compensation. With a degree of stenosis of more than 70 %, mesenteric ischaemic pain and physical prostration are the major clinical findings. Intestinal infarction with a mortality rate of 60-80 % is the endpoint of the chronically progressive intestinal ischaemia. There-fore, an urgent medical treatment is highly required. CT angiography is the diagnostic procedure of choice in patients with suspected chronic intestinal ischaemia. Mesenteric angiography is subject to specific questions and / or to endovascular arteriographic treatment. Duplex scanning has been advocated as a non-invasive method of pre- and post-interventional screening. Treatment is indicated in symptomatic intestinal vascular disease. Due to the high morbidity of the majority of patients and the enormous invasivity associated with conventional surgery, arteriographic intervention is the treatment of choice, even though quality improvement is required. Surgical reconstructions are highly standardised and should be associated with perioperative mortality less than 3 %. We recommended the reconstruction of 2 vessels, for which antegrade supracoeliacal revascularisation techniques are favourable. In (threatening) septic conditions, autologous reconstructions are required. Intestinal infarction is the most serious complication of all visceral revascularisations. In recurrent occlusions of visceral arteries, it is recommended to favour and finally use a different therapeutic modality. Post-therapeutic care includes second-look operation as well as clinical examination and diagnostic imaging. Antithrombotic therapy should be initiated. The further screening of patients after intestinal revascularisation should be performed by duplex scanning. Chronically progressive occlusive disease of intestinal arteries is considered as a complex disease with challenging diagnostic and therapeutic management, in which an interdisciplinary, partly finding- and stage-dependent (also with regard to the frequency and recurrency of the specific local finding) sequential therapeutic approach (e. g., endovascular vs. open procedure; interventionalist / endovascular specialist / vascular surgeon) becomes more and more relevant requiring a competent center of vascular medicine.

Bleeding Duodenal Varices Successfully Treated with Balloon-Occluded Retrograde Transvenous Obliteration (B-RTO) Assisted by CT During Arterial Portography

A 60-year-old woman with massive hemorrhage from duodenal varices was transferred to our hospital for the purpose of transcatheter intervention. Although digital subtraction arterial portography could not depict the entire pathway of collateral circulation, the efferent route of the duodenal varices was clearly demonstrated on subsequent CT during arterial portography. Balloon-occluded retrograde transvenous obliteration (B-RTO) of the varices was performed via the efferent vein and achieved complete thrombosis of the varices.

Internal carotid artery stenosis or occlusion: study of collateral circulation pathways on DSA and MRA

目的 研究DSA、MR血管成像(MRA) 对颈内动脉狭窄或闭塞后侧支循环途径评价的意义.方法颈内动脉狭窄或闭塞者74例,DSA和MRA上脑血管正常表现者各60例为对照组,分析其DSA和MRA表现.结果 74例患者均有颈内动脉分叉以上狭窄或闭塞.病变同侧后交通动脉在DSA上的出现率,疾病组低于对照组(P=0.025);在时间飞跃(TOF)法MRA上的出现率,疾病组明显高于对照组(P=0.000).后交通动脉DSA、MRA测量值均较对照组增大(P＝0.000).眼动脉直径DSA测量值较对照组增大 (P＝0.003).疾病组后交通动脉出现率在DSA上高于MRA (P<0.05).结论 DSA对本病侧支途径评价有重要意义,为术前必要检查.MRA安全,可从形态和功能上评价侧支循环,可做为首选方法。

Effectiveness of Bypass Surgery in Treatment and Prevention for Cerebrovascular Occlusive Disease

To study the effect of extracranial-intracranial(EC/IC) bypass on symptomatic patients with hemodynamic cerebral ischemia, we prospectively reviewed 76 patients who underwent EC/IC bypass surgery in patients with occlusive cerebrovascular disease. A series of 76 patients treated in a 7 years period met following criteria. ① symptomatic internal carotid artery(ICA) or middle cerebral artery(MCA) obstruction or stenosis over 80%. ② decrease in basal cerebral blood flow(CBF) over 10%. ③ decreased reactivity of CBF in response to acetazolamide. Among these, the types of ischemic episodes were transient ischemic attack(TIA) or reversible ischemic neurological deficit(RIND) in 39, minor stroke in 22, and major stroke in 15. Based on our criteria, superficial temporal artery(STA)-MCA anastomosis was performed in 67 cases and EC-IC bypass grafting using saphenous vein or radial artery in 9. Average follow up period was 26 months(3 months~7 year). Patency of bypass was confirmed by postoperative angiography or magnetic resonence angiography(MRA) in all case except four cases. Of the 72 patients with patiency of bypass, 68 patients(94%) have had an excellent to good outcome with improvement of preoperative neurologic or cognitive dysfunction, 3 patients showed no improvement of preoperative neurologic symptoms and remaining one patient had new developed deficit. All 72 patients with patency of bypass had experienced no further cerebral ischemic events during following period. Postoperative significant improvement of CBF to acetazolamide was showed in 68 cases(94%) of the 72 cases with patency of bypass, while the basal CBF showed significant improved in 31cases. Postoperative permanent neurologic deficit occurred only in one. In view of these finding, the author suggest that EC-IC bypass surgery is a reliable and resonably safe method for establishing new pathways of collateral circulation to the brain and to be considered as an appropriate therapy for improvement of the cerebrovascular reserve capacity in patients with hemodynamic cerebral ischemia, defined using the strict selection criteria employed in this study.

Breast varices: imaging findings of an unusual presentation of collateral pathways in superior vena caval syndrome

Imaging findings are presented of an unusual pathway of collateral circulation consisting of bilateral and diffuse dilated breast veins from a patient with long standing superior vena caval syndrome. The main importance of this case is the extent of the collateral development through the breast veins, serving as the major pathway of collateral circulation. Identification of this unusual collateral development, which resembles breast varices, was performed with contrast-enhanced chest CT scans, digital subtraction venography, color Doppler ultrasonography, and mammographic studies. Collateral development was secondary to a long segment idiopathic venous occlusion involving bilateral subclavian and brachiocephalic veins as well as vena cava superior. We conclude that dilated breast veins when detected on any imaging modality should raise the suspicion of central venous obstruction.

The Development of Collateral Circulation in Patients with Total Occlusion of Coronary Artery and its Clinical Significance

Background and Objectives:Coronary collateral circulation is known to have beneficial effects in patients with angina pectoris and myocardial infarction. The purpose of this study is to determine the predictors of collateral vessels development, the pathways of collateral circulation and the changes in collateral flow after coronary intervention and its functional significance in patients with total occlusion. Materials and Methods: One hundred thirty five patients who underwent coronary angiogram between Jan ’97 and Dec ’97 in Chonnam University Hospital (out of 3,264 cases) had total occlusion of one coronary artery were classified into two groups;angina pectoris (Group I:50 M, 19 F, 62.4±11.0 years) and acute myocardial infarction (Group II:47 M, 19 F, 62.0±9.5 years). Results:Among 135 patients, 123 patients had collateral circulation. Collaterals were more frequently observed and better developed (grade 2 or 3) in Group I than Group II. Proximal and ostial lesions were associated with well developed collaterals. Collateral circulation was more frequently observed and well developed in proportion to the duration of angina in Group I. In 123 patients with collateral circulation, 247 collateral circulations were observed. Right coronary artery (RCA) and Left circumflex coronary artery (LCX) were more frequent recipient arteries than left anterior descending coronary artery (LAD)(RCA:2.20±1.02, LCX:1.88±0.94, LAD:1.29±0.8 respectively, RCA vs. LAD:p<0.001, LCX vs. LAD:p=0.014). Coronary interventions were performed in 50 out of 135 patients, collateral flow of Group II decreased much more than Group I after intervention (Group I:5/14, Group II: 24/36, p=0.046). The wall motion score was lower in patients with well developed than poorly developed collaterals (20.7±4.91 vs. 23.7±6.22, p=0.015). Conclusion:Proximal or ostial lesion and duration of 논문접수일:1999년 8월 24일 심사완료일:2000년 2월 17일 교신저자:정명호, 501-757 광주광역시 동구 학1동 8번지 전남대학교병원 심장센터 전화:(062) 220-6243·전송:(062) 228-7174 E-mail:myungho@chollian.net

Subclavian steal from the external carotid circulation

Three cases of subclavian steal syndrome with contribution to the retrograde flow of blood in the vertebral artery by the external carotid system are presented. In 1 patient progressive enlargement of an extracranial-intracranial bypass was demonstrated angiographically as the steal from the external carotid system was reduced. It is suggested that this pathway of collateral circulation may not be uncommon, and its recognition may influence the selection of procedure and timing of operation for revascularization of the brain.

Collateral pathways in inferior vena caval obstruction in children, including the cavo-portal route.

An analysis of iliocavograms in 75 children, aged 12 days to 14 years demonstrated the main pathways of collateral circulation in cases of occlusion of the inferior vena cava. Three cases of children with cavo-portal links via the inferior epigastric veins and persistent umbilical vein to the portal system are presented for the first time in the English literature.

Studies on anomalous collateral systemic-pulmonary circulation. Report of four cases.

The circulatory status of four patients with anomalous systemic-pulmonary circulations has been studied by bronchospirometry, cardiac catheterization, angiography, and dye-dilution techniques. In three of these patients the affected lung was smaller than normal, and bronchography showed no abnormalities. On the affected side angiography failed to show filling of the pulmonary artery, and the oxygen uptake appeared to be zero or minimal. In two of the patients bronchospirometry revealed an effective collateral circulation, whereas the dye-dilution curves were almost normal. In the other patient there was anatomic evidence of both transpleural systemic-pulmonary arterial communication and occlusive disease of the pulmonary veins. Here the dye-dilution curves revealed considerable shunting of blood, whereas no effective collateral circulation could be demonstrated. The fourth patient has extensive unilateral bronchiectasis and illustrates the condition wherein neither pulmonary nor systemic blood flows through the pulmonary capillary bed. The pathogenesis of the various pathways of collateral circulation is discussed, as well as some methodological and technical problems.

A technique for postmortem coronary arteriography

A simple method for the postmortem roentgenographic demonstration of the arterial supply of the human heart is described. This technique eliminates the disadvantages of previously utilized methods in that it is technically simple, is less time consuming, and does not alter or destroy the specimen for subsequent gross or microscopic examination. The roentgenograms taken of the heart after injection of the iodized oil into the coronary arteries have vividly demonstrated arteriosclerotic plaques, occluded vessels, and the pathways of collateral circulation. These advantages make this method readily adaptable for routine postmortem examination of the coronary circulation.