Well-developed Collaterals Research Articles

Venous retrograde approach for endovascular angioplasty in chronic total pulmonary vein occlusion -a case report

IntroductionFibrosing mediastinitis (FM) is a rare disease characterized by excessive proliferation of fibrous tissue in the mediastinum and can cause bronchial stenosis, superior vena cava obstruction, pulmonary artery and vein stenosis, etc.Case presentationAn aging patient with intermittent chest tightness and shortness of breath was diagnosed with FM associated pulmonary hypertension (FM-PH) by echocardiography and enhanced CT of the chest, and CT pulmonary artery (PA)/ pulmonary vein (PV) imaging revealed PA and PV stenosis. Selective angiography revealed complete occlusion of the right upper PV, and we performed endovascular intervention of the total occluded PV. After failure of the antegrade approach, the angiogram revealed well-developed collaterals of the occluded RSPV-V2b, so we chose to proceed via the retrograde approach. We successfully opened the occluded right upper PV and implanted a stent.ConclusionsThis report may provide new management ideas for the interventional treatment of PV occlusion.

Pancreatectomy with En Bloc Superior Mesenteric Vein and All Its Tributaries Resection without PV/SMV Reconstruction for "Low" Locally Advanced Pancreatic Head Cancer.

The "vein definition" for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for "low" LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality; overall morbidity-56%; Dindo-Clavien-3-10.5%; R0-rate-82%; mean operative procedure time-355 ± 154 min; mean blood loss-330 ± 170 mL; delayed gastric emptying-25%; and clinically relevant postoperative pancreatic fistula-8%. In three cases, surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2-3 days-long intestinal edema (48%). Median overall survival was 25 months, and median progression-free survival was 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were as follows: (1) preserved SMV-SV confluence; (2) occluded SMV for any reason (tumor or thrombus); (3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; (4) no right-sided vein collaterals; and (5) no varices in the upper abdomen. Conclusion: "Low" LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate.

The prognostic value of collateral circulation in coronary chronic total occlusion underwent percutaneous coronary intervention.

The prognostic value of coronary collateral circulation (CC) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is underdetermined. The purpose of the study was to assess the prognostic value of current two CC grading systems and their association with long-term outcomes in patients with CTO underwent PCI. We consecutively enrolled patients with single-vessel CTO underwent PCI between January 2010 and December 2013. All patients were categorized into well-developed or poor-developed collaterals group according to angiographic Werner's CC (grade 2 vs. grade 0-1) or Rentrop (grade 3 vs. grade 0-2) grading system. The primary endpoint was 5-year cardiac death. Of 2452 enrolled patients, the overall technical success rate was 74.1%. Well-developed collaterals were present in 686 patients (28.0%) defined by Werner's CC grade 2, and in 1145 patients (46.7%) by Rentrop grade 3. According to Werner's CC grading system, patients with well-developed collaterals had a lower rate of 5-year cardiac death compared with those with poor-developed collaterals (1.6% vs. 3.3%, P = 0.02), those with suboptimal recanalization was associated with higher rate of 5-year cardiac death compared with optimal recanalization (4.7% vs. 0.8%, P = 0.01) and failure patients (4.7% vs. 1.6%, P = 0.12). However, the similar effect was not shown in Rentrop grading system. In patients with the single-vessel CTO underwent PCI, well-developed collaterals by Werner's CC definition were associated with lower rate of 5-year cardiac death. Werner's CC grading system had a greater prognostic value than Rentrop grading system in patients with CTO underwent PCI.

Inquiring about the link between urotensin-II and coronary collateral development in coronary artery patients with and without diabetes

Aims: Coronary collateral circulation consists of vascular channels activated to maintain perfusion in major epicardial coronary arteries in severe stenosis or occlusion. Yet, coronary collateral development (CCD) in diabetic patients was previously proven to be poor. Urotesin-II (U-II) is famous for being the most potent vasoconstrictor agent, and plasma levels are known to elevate in diabetic patients and play an important role in diabetic complications. In this study, we inquired about the link between U-II levels and the development of coronary collaterals between diabetic and non-diabetic patients with coronary artery disease (CAD).
 Methods: We recruited 31 diabetic and 30 non-diabetic patients with 95% or more coronary artery stenosis or occlusion and considered Rentrop’s classification for grading collaterals. In this sense, while Rentrop grades 0-1 are regarded as poor CCD, Rentrop grades 2-3 correspond to well-developed collaterals. Moreover, we compared the patients’ serum levels of U-II by the degree of CCD.
 Results: The findings revealed that demographic characteristics did not significantly differ between the groups (p >0.05). Although CCD seemed worse in diabetic patients than those without diabetes (DM), the finding was not statistically significant. However, the diabetic patients had significantly higher U-II levels than non-diabetic patients (388.1±314.2 vs. 229.8±216.9, p=0.026). Despite not being significant, U-II levels were higher in patients with poor CCD than those with well-developed collaterals in the non-diabetic group (370.6±298; 178.6±158.3, p=0.2). In the diabetic group, on the other hand, U-II levels were significantly higher in patients with poor CCD and significantly lower in patients with good CCD (582.7±316.4 and 180.4±121.6, respectively; p

Incidence, Predictors, and Strategies for Retrograde Wire Tracking Failure via Poor Septal Collateral Channels in Chronic Total Occlusion.

Retrograde guidewire (GW) tracking success via a poor septal collateral channel (CC) when an antegrade approach fails is crucial for successful revascularization of coronary chronic total occlusion (CTO) with poor septal CC. However, the incidence, predictors, and management strategies for retrograde GW tracking failure via poor septal CC remain unclear. In total, 122 CTO patients who underwent retrograde septal percutaneous coronary intervention (PCI) with poor CC between January 2017 and May 2022 were retrospectively analyzed. Patients were divided into the retrograde GW tracking success group (success group) and the retrograde GW tracking failure group (failure group). Clinical and angiographic data were compared to investigate the predictors of retrograde GW tracking failure. The incidence of GW tracking failure was 22.1% (27/122). Patients in the failure group had a higher prevalence of left anterior descending artery (LAD) CTO (66.7% vs 37.9%; p = 0.009) and a higher incidence of well-developed non-septal collateral (66.7% vs 30.5%; p = 0.001). Patients with a septal CC diameter ≥ 1 mm (48.1% vs 70.5%; p = 0.040), ≥ 3 septal CCs (44.4% vs 66.3%; p = 0.046), and initial retrograde application of Guidezilla (37.0% vs 60.0%; p = 0.048) were significantly lower in the failure group than in the success group. The binary logistics regression model showed that a CC diameter < 1 mm, well-developed non-septal collateral, and LAD CTO were independent predictors for GW tracking failure in patients undergoing retrograde CTO PCI via poor septal CC. The success rate of retrograde GW tracking via poor septal CC was high, with a relatively high procedural success rate. A CC diameter < 1 mm, well-developed non-septal collateral, and LAD CTO were independent predictors of GW tracking failure in patients undergoing retrograde CTO PCI via poor septal CC.

Retrograde percutaneous coronary intervention of chronic total occlusion via discontinuous septal channels.

The study aims to investigate the safety and feasibility of retrograde CTO intervention via collateral connection grade 0 (CC-0) septal channel and to identify predictors of collateral tracking failure. Guidewire crossing a collateral channel is a critical step for successful retrograde percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Retrograde PCI was attempted in 122 cases of CTO with CC-0 septal collaterals from December 2018 to May 2021. A hydrophilic polymer coating guidewire was used for crossing all intended CC-0 collaterals. A multivariable logistic regression analysis was performed to identify the predictors of guidewire tracking failure via the CC-0 collaterals. Successful guidewire tracking via CC-0 septal channel was achieved in 98 (80.3%) of 122 cases. The independent predictors of CC-0 septal channel guidewire tracking failure included well-developed non-septal collateral (OR: 5.297, 95% CI: 1.107-25.353, p = 0.037) and the ratio length of posterior descending artery (PDA) versus the distance of PDA ostium to cardiac apex ≤2/3 (OR: 3.970, 95% CI: 1.454-10.835, p = 0.007). Collateral perforation, target vessel perforation, and cardiac tamponade occurred in 5 (4.1%), 3 (2.5%), and 6 (4.9%) cases, respectively. There were no complications requiring emergency cardiac surgery or revascularization of nontarget vessel. Retrograde PCI via CC-0 septal channels with a hydrophilic polymer-coated guidewire is feasible and safe in patients with CTO. Well-developed nonseptal collaterals and short PDA length influence the procedure success and the risk of guidewire tracking failure via CC-0 septal channels.

806 BRIDGING COLLATERALS OF CHRONICALLY OCCLUDED LEFT INTERNAL MAMMARY ARTERY BYPASS GRAFT TO LEFT ANTERIOR DESCENDING ARTERY

Abstract Methods and results The internal mammary artery (IMA) is the conduit of choice to bypass the left anterior descending (LAD) coronary artery in patients eligible for coronary artery bypass grafting (CABG). In case of graft occlusion, it is still not clear whether it is better to revascularize the graft or the recipient native vessel, on top of optimal medical therapy. A 55-year-old man, with prior CABG, underwent urgent coronary angiography for an acute coronary syndrome. LAD CTO, severe proximal circumflex artery stenosis, and mild atherosclerosis of the right coronary artery were found. Moreover, a proximal occlusion of the venous graft to the obtuse marginal branch and LIMA CTO within the body of the graft were shown as well. Surprisingly, many well-developed bridging collaterals, arising close to the proximal cap of the LIMA occlusion, supplied the bloodstream circulation distal to the occlusion within the LIMA. At that time, a left main–proximal circumflex artery stenting was performed (3.5×24-mm Xience Sierra, Abbott) because that was judged the culprit lesion. One month later the patient still complained of effort angina and dyspnoea despite optimized antianginal medical therapy. The patient was scheduled for elective antegrade LIMA CTO PCI, considered the most appropriate treatment strategy. Indeed, the presence of a prior stent implanted in the left main– circumflex artery would have made difficult a proximal cap negotiation and its penetration by guidewires in case of antegrade LAD CTO PCI. Thus, the LIMA CTO negotiation was initially attempted with a Fielder FC guidewire (Asahi Intecc) and a supporting Corsair Pro (Asahi Intecc) microcatheter. The polymeric soft wire prolapsed preferentially into the bridging collaterals without the chance to engage the CTO proximal cap. Finally, a moderate-weight hydrophilic GAIA second (Asahi Intecc) succeeded in cap penetration and final CTO crossing. After lesion predilatation with a 2.0×15-mm balloon (Emerge, Boston Scientific), 2 overlapped stents, respectively 2.75×44 mm and 3.0×18 mm (VIVO ISAR, Translumina) were deployed and postdilated by a 3.0×15-mm non-compliant balloon (Accuforce, Terumo). The final result was deemed very satisfactory with a TIMI 3 flow. Conclusions Many studies showed that IMA has active biological functions, providing a sort of protection against atherosclerosis and self-reparative properties. These biological properties might justify the IMA high long-term patency rates as CABG conduits. The development of bridging collaterals in this patient, represents a clear proof of the LIMA self-reparative properties. Whereas bridging collaterals are a common feature of coronary CTO, their development in a LIMA bypass graft represents a unique finding which requires further investigation.

The association of collaterals with myocardial ischemia and viability in chronic total occlusions.

Collateral development in chronic total occlusions (CTO) is crucial to perfuse the distal myocardium and its angiographic evaluation is frequently used to assess the need for revascularization. We aimed to analyse the association between the presence of ischemia and hibernating myocardium, evaluated by cardiac [13N]NH3/2-[18F]FDG PET-CT, and the angiographic characterization of the collateral circulation. Prospective study including patients with a CTO who underwent a [13N]NH3 and, when deemed necessary, 2-[18F]FDG PET-CT. Well developed (WD) collaterals were defined as a concomitant angiographic Rentrop grade 3 and Werner collateral connection score 2 or 3, whereas the remaining as poorly developed (PD). 2% thresholds used to identify prognostic benefit of revascularization were applied: ischemia > 10% and hibernating myocardium > 7%. Fifty-nine patients (age 62.9±9.1 years, 58 male) were recruited, WD collaterals were present in 28 (47.5%). No significant differences were found in ischemia (WD 6.4±4.3 vs. PD 7.0±4.1, p = 0.64) and hibernation (WD 1.8±1.9 vs. PD 3.1±3.3, p = 0.18) scores. Most CTO territories demonstrated ischemia, but only 19 (46.3%) were associated with an area > 10% (WD 47.6% vs. PD 45.0%, p = 0.58). Scared non-viable myocardium was limited to 9 (15.3%) patients and was not associated with PD collaterals. Hibernating myocardium was frequent (54.2%), but just 6 (10.2%) CTO patients had an area of > 7% (WD 3.6% vs. PD 16.1%, p = 0.20). Collateral assessment by angiography has a poor association with the ischemic burden and hibernation state of CTO territories. Myocardial viability was present even in most CTO with angiographic PD collaterals.

Role of collateral flow in infarct border zone extent and contractile function in patients with chronic coronary total occlusion

PurposeThere is a paucity of data regarding the border zone parameters in patients with chronic coronary total occlusion (CTO). We investigated the border zone extent and contractile function and their associations with collateral flow. MethodsCTO patients (n = 47) and sex- and age-matched volunteers (n = 15) were prospectively enrolled and underwent cardiac MRI examinations to acquire cine and late-gadolinium enhancement (LGE) images. Myocardial peak strain (PS) and the time to PS were determined at the segmental level and global level. Infarct, border zone, adjacent, and remote regions were defined according to the transmural extent of infarction (TEI) by LGE at each segment. Angiographic collateral flow was evaluated using the Rentrop grading system. ResultsCTO patients with well-developed collateral flow had a higher TEI in border zone regions compared to patients with poorly developed collateral flow (p = 0.02). Conversely, CTO patients with poorly developed collaterals showed a higher TEI in infarct regions (p < 0.01). Enhanced border function, characterized by greater PS and earlier time to PS, was noted in well-developed collaterals (all p < 0.05). In the multivariate linear analyses, the level of collateral flow was an independent predictor of the border zone extent (β = 0.40, p = 0.02) and contractile function (radial: β = -0.42, p = 0.02; circumferential: β = 0.39, p = 0.02; and longitudinal: β = 0.47, p < 0.01). ConclusionsIn CTO patients, the presence of well-developed collateral flow was closely linked to a greater extent of LGE and contractile function in border zone regions. Our findings shed light on the cardiac MRI-based pathophysiological underpinning in border zone regions, which could offer complementary and prognostic information in clinical practice.

The association of new atherosclerosis markers with coronary collaterals in chronic total occlusion patients

Objectives: In the present study, we investigated the relationship between mentioned markers and chronic total occlusion collateral development. Patients and methods: A total of 243 patients (210 males, 33 females; mean age: 63.3±11.5; range, 51 to 76 years) who underwent coronary angiography due to typical chest pain or myocardial ischemia detected in noninvasive stress tests and diagnosed with ≥1 major coronary artery occlusion between January and September 2020 were included in the cross-sectional observational study. The angiographic collateral index was determined according to the Cohen-Rentrop classification. The patients were divided into two groups according to the sufficiency of collateral development: the well-developed collaterals group (n=155) and the poor-developed collaterals group (n=88). Results: Statistically significant parameters in univariate logistic regression analysis were evaluated with multivariate (stepwise) logistic regression analysis; as a result, presence of chronic total occlusion in left anterior descending artery (odds ratio [OR]=2.447; 95% confidence interval [CI], 1.160-5.162; p=0.019), total number of occlusions (OR=3.503; 95% CI, 1.445-8.494; p=0.006), left ventricular ejection fraction (OR=1.056; 95% CI, 1.022-1.091; p=0.001), and the atherogenic index of plasma (OR=0.017; 95% CI, 1.022-1.091; p&lt;0.001) were independently associated with well-developed collaterals. Although the triglyceride-glucose index had statistical significance in the univariate analysis, it was not detected as an independent variable in the multivariate analysis. The monocyte-lymphocyte ratio was not significant in the univariate analysis. Conclusion: Of the new atherosclerosis markers, only the atherogenic index of plasma had an independent association with poor collateral development.

Collateral presence and extent do not predict myocardial viability and ischemia in chronic total occlusions: A stress-CMR study

BackgroundWell-developed collaterals are assumed as a marker of viability and ischemia in chronic total occlusions (CTO). We aim to correlate viability and ischemia with collateral presence and extent in CTO patients by cardiac magnetic resonance (CMR). MethodsMulticentre study of 150 CTO patients undergoing stress-CMR, including adenosine if normal systolic function, high-dose-dobutamine for patients with akinetic/>2 hypokinetic segments and EF ≥35%, otherwise low-dose-dobutamine (LDD); all patients underwent late gadolinium enhancement (LGE) imaging. Viability was defined as mean LGE transmurality ≤50% for adenosine, as functional improvement for dobutamine-stress-test, ischemia as ≥1.5 segments with perfusion defects outside the scar zone. ResultsRentrop 3/CC 2 defined well-developed (WD, n = 74) vs poorly-developed collaterals (PD, n = 76). Viability was equally prevalent in WD vs PD: normo-functional myocardium with ≤50% LGE in 52% vs 58% segments, p = 0.76, functional improvement by LDD in 48% vs 52%, p = 0.12. Segments with none, 1–25%,26–50%,51–75% LGE showed viability by LDD in 90%,84%,81%,61% of cases, whilst in 12% if 76–100% LGE (p < 0.01). There was no difference in WD vs PD for ischemia presence (74% vs 75%, p = 0.99) and extent (2.7 vs 2.8 segments, p = 0.77). ConclusionsIn a large cohort of CTO patients, presence and extent of collaterals did not predict viability and ischemia by stress-CMR. Scar extent up to 75% LGE was still associated with viability, whereas ischemia was undetectable in 25% of patients, suggesting that the assessment of CTO patients with CMR would lead to a more comprehensive evaluation of viability and ischemia to guide revascularization.

Kazakhstan CTO Club's recommended guidelines for interventional therapy for coronary chronic total occlusion

Chronic total occlusion (CTO) disease refers to obstructive coronary artery disease, which is the degree of direct blood flow of the blood flow TIMI 0 degree of occlusion time 3 months, if there are already well-developed collaterals or bridge collaterals, the distance from the occlusion of the blood vessel TIMI blood flow > 0 degree is still considered a total occlusion disease. Previous studies have shown that 20% of patients with coronary heart disease have experienced CTO lesion from at least one vessel, Percutaneous Coronary Intervention (PCI) surgery is called the

Serum CTRP9 Reflects Coronary Collateralization in Nondiabetic Patients with Obstructive Coronary Artery Disease

Aim To explore the association between the serum C1q/tumor necrosis factor-related protein 9 (CTRP9) and the formation of coronary collateral circulation in obstructive coronary artery disease (CAD). Methods A total of 206 patients who underwent coronary angiography at Beijing Anzhen Hospital and had epicardial arteries with at least 95% stenotic lesion were enrolled. Blood samples were taken after an overnight fasting before the coronary angiography. Serum CTRP9 level was measured using commercial enzyme linked immunosorbent assay (ELISA) kit. The development of coronary collateralization was determined according to the Rentrop classification system. Rentrop score 0-1 was graded as impaired or less-developed coronary collateralization (n = 54) while the Rentrop score 2-3 was defined as well-developed collateralization (n = 152). Results Serum CTRP9 level was significantly higher in well-developed collateralization and diabetes groups (P < 0.001). To further explore the association between the CTRP9 level and coronary collateralization, the enrolled participants were divided into 3 tertiles according to the serum CTRP9 level. The prevalence of impaired coronary collateralization decreased stepwise with the increasing CTRP9 tertiles (P for trend <0.001). Multivariate regression analysis showed that the serum CTRP9 is independently associated with well-developed collateralization, with an OR (95% CI) of 4.49 (1.75-11.55) and 8.98 (2.75-29.35) in the tertiles 2 and 3, respectively. The following subgroup and receiver-operating characteristic (ROC) analysis also indicated that the diagnostic value of serum CTRP9 level for detecting the formation of collateralization persisted only in nondiabetic participants. Lastly, adding the serum CTRP9 into the baseline model could increase the diagnostic value of established model consisting of relevant factor for the discrimination of well-developed collateralization only in the nondiabetic group (P = 0.046). Conclusions Serum CTRP9 reflects well-developed coronary collateralization in nondiabetic patients with obstructive CAD, and CTRP9 level ≥ 1.217 indicated a greater chance to forming well-developed coronary collaterals.

Clinical Outcomes Of A Diagnostic And Management Protocol For Popliteal Artery Entrapment Syndrome At A Large Referral Center

<h3>OBJECTIVE</h3> Popliteal Artery Entrapment Syndrome (PAES) is a rare clinical entity without a standardized algorithm for diagnosis. Our objective was to evaluate clinical outcomes using a unique diagnosis and management algorithm for PAES. <h3>METHODS</h3> We retrospectively reviewed patients diagnosed with PAES at a single institution between 2013 and 2021. Demographics, physical exam findings, non-invasive imaging results, and angiographic images were assessed to validate a diagnostic and management algorithm (Figure 1). <h3>RESULTS</h3> Thirty extremities in 20 patients were treated for PAES (Table 1). Physical exam revealed a pulse decrement with provocative maneuvers in 90% of treated limbs. Noninvasive studies to include treadmill exercise testing revealed a mean ABI drop of 0.27 and positional duplex demonstrated peak systolic velocity increase by a mean ratio of 1.72 with provocative maneuvers. DiagnosticImage, figure 1 arteriography was performed in all patients and revealed well-developed collaterals in 100% of treated limbs and complete effacement of the popliteal artery with active provocative maneuvers. Surgical exposure occurred via a posterior approach using a longitudinal incision and intraoperative duplex was performed in all cases. Staged bilateral PAES release occurred in 10 patients and type III PAES was diagnosed in 90%. Wound complications occurred in 4 limbs and included seroma and hypertrophic scarring. All patients experienced symptomatic relief with median follow-up of 4 months. <h3>CONCLUSIONS</h3> We report 100% technical and clinical success in patients with PAES diagnosed and managed using our clinical algorithm. Dynamic angiography to confirm the diagnosis and intraoperative duplex to confirm complete surgical release are essential for successful clinical outcome.Image, table 1Image, table 1

401 Myocardial viability and ischaemia assessment in chronic coronary total occlusions according to collaterals distribution: a retrospective analysis

Abstract Aims Whether CTO-PCI (chronic total occlusions—percutaneous coronary intervention) offers clinical benefit over optimal medical therapy is still a matter of debate. Viability and ischaemia assessment could improve selection of candidates to PCI. Traditionally, well-developed collaterals are considered a marker of myocardial viability in CTO territory. Current literature offers few data concerning the relationship between viability/ischaemia and collaterals distribution. Methods and results We retrospectively analysed the Cardiovascular Magnetic Resonance (CMR) studies and coronary angiographies of patients with at least one CTO referred at Humanitas Research Hospital between June 2009 and September 2020. We included 131 patients who underwent CMR with LGE assessment; of them, 111 (85%) underwent stress-CMR with adenosine. AHA segments (16 segment/patient for a total of 2096 segment assessed) were assessed on three short axis projection and scored for WMSI on cine images, for the presence of ischaemia on first pass perfusion, and for viability on LGE images. Viability was defined as LGE transmurality ≤50% and WMSI (wall motion score index) &amp;gt;1. Patients were divided in three groups according to collaterals distribution at coronary angiography: Patients with TD collaterals were more likely to have viable segments in the CTO-territory (90% of the segments in TD, 76% in WD, and 71% in PD, coeff. 0.107, P &amp;lt; 0.001). No statistically significant differences were found between groups as regard the amount of ischaemic segments (61% of the segments in TD, 65% in WD, and 60% in PD, P = 0.189). Conclusions The presence of myocardial viability is slightly associated with the degree of coronary collateralization at coronary angiography while the amount of ischaemia is not. Stress CMR should be considered in CTO patients before a reopening attempt.

Myocardial Viability, Functional Status, and Collaterals of Patients With Chronically Occluded Coronary Arteries.

Objective: Viability and functional assessments are recommended for indication and intervention for chronic coronary total occlusion (CTO). We aimed to evaluate myocardial viability and left ventricular (LV) functional status by using cardiovascular magnetic resonance (CMR) and to investigate the relationship between them and collaterals in patients with CTO.Materials and Methods: We enrolled 194 patients with one CTO artery as detected by coronary angiography. Patients were scheduled for CMR within 1 week after coronary angiography.Results: A total of 128 CTO territories (66%) showed scar based on late gadolinium enhancement (LGE) imaging. There were 1,112 segments in CTO territory, while only 198 segments (18%) subtended by the CTO artery showed transmural scar (i.e., >50% extent on LGE). Patients with viable myocardium had higher LV ejection fraction (LVEF) (56.7 ± 13.5% vs. 48.3 ± 15.4%, p < 0.001) than those with transmural scar. Angiographically, well-developed collaterals were found in 164 patients (85%). There was no significant correlation between collaterals and the presence of myocardial scar (p = 0.680) or between collaterals and LVEF (p = 0.191). Nevertheless, more segments with transmural scar were observed in patients with poorly-developed collaterals than in those with well-developed collaterals (25 vs. 17%, p = 0.010).Conclusion: Myocardial infarction detected by CMR is widespread among patients with CTO, yet only a bit of transmural myocardial scar was observed within CTO territory. Limited number of segments with transmural scar is associated with preserved LV function. Well-developed collaterals are not related to the prevalence of myocardial scar or systolic functioning, but could be related to reduce number of non-viable segments subtended by the CTO artery.

Anomalous origin of left main coronary artery from pulmonary artery: Patient characteristics and imaging associations on multidetector computed tomography angiography.

To evaluate the various imaging features and associations on multidetector computed tomography (CT) angiography in patients with anomalous origin of left main coronary artery (LMCA) from pulmonary artery (ALCAPA). We retrospectively reviewed multidetector CT angiography studies done for the evaluation of congenital heart diseases at our institution through 2014 to 2021. Cases with ALCAPA were identified and relevant history and imaging findings including the origin of coronary arteries, left ventricular (LV) morphology and functions, intercoronary collaterals, and associated abnormalities were evaluated. Twelve patients (eight males,three adults, and nine children; age range: 2 months to 54 years) with ALCAPA were included. Gradually progressive dyspnea and failure to thrive (6/9; 66.67% each) were the most common symptoms amongchildren, whereas adults were commonly asymptomatic (2/3; 66.67%). The LMCA was originating from pulmonary sinus, main, and right pulmonary artery in 6 (50%), 5 (41.66%), and 1 (8.3%) patients, respectively. In adult-type ALCAPA, right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCx) were dilated and tortuous, with the presence of well-developed intercoronary collaterals and preserved LV ejection fractions; these features were not seen in patients of infantile ALCAPA. LV dysfunction with global hypokinesia was the most common wall motion abnormality (7/12; 58.33%). Degree of collateralization could be the key factor determining the time of presentation, clinical symptoms, and LV function, thus influencing clinical outcomes. Patients with infantile ALCAPA present with features of heart failure and have dilated and dysfunctional LV consequent to lack of collaterals, unlike adult-type ALCAPA.

Does the extent of collaterals influence the severity of the myocardial injury as assessed by elevation in biomarkers?

Introduction: Quantitative analysis of cardiac biomarkers, troponin I and CPK-MB, estimates the extent of myocardial injury while extent of benefit from coronary collateral circulation (CCC) to protect myocardium during acute myocardial infarction (AMI) needs validation. We analysed if the extent of collaterals had impact on baseline biomarkers at the time of coronary angiogram. Methods: We analysed 3616 consecutive patients who presented with AMI and underwent invasive coronary angiography (CAG) with intent to revascularisation with biomarkers assessment at the time of CAG. CCC to Infarct related artery (IRA) were graded as per Rentrop grading viz. poorly-developed CCC (Grade 0/1 as Group A) and well-developed CCC (Grade 2/3 as Group B). Results: Both groups (A and B) were matched for demographics, traditional risk factors, SYNTAX 1 Score, time to CAG from onset of angina and eGFR. 36.59% of patients had Non-ST segment elevation myocardial infarction (NSTEMI) as compared to 63.41% ST -segment elevation infarction (STEMI). Overall Troponin I (P =0.01, P =0.01) and CPK MB (P =0.00, P =0.002) values were lower in group B in both NSTEMI and STEMI groups respectively. Troponin I and CPK-MB were significantly lower in group B [with NSTEMI for SVD (Single vessel disease) (P =0.05) and DVD (Double vessel disease) (P =0.04),but not for TVD (Triple vessel disease) and with STEMI in SVD (P =0.01), DVD (P =0.01) and TVD (P =0.001)]. Conclusion: Patients with well-developed coronary collaterals had a lower rise in biomarkers in AMI as compared to those with poor collaterals amongst both NSTEMI and STEMI groups.

Resection of Inferior Vena Cava Without Reconstruction for Intravascular Intrusion of Wilms Tumor

Persistent inferior vena cava (IVC) tumor thrombus in Wilms tumor patients represents a management challenge. We describe three pediatric cases with preoperative evaluation documenting complete IVC occlusion and well-developed collaterals. They underwent nephrectomy and tumor thrombus removal accomplished with circumferential resection of the retrohepatic IVC without vascular reconstruction. All patients are asymptomatic and disease-free at 9, 2.5, and 2 years after stopping therapy. Cavectomy without reconstruction is safe and well tolerated in Wilms tumor patients with completely occlusive IVC tumor thrombus. Additionally, when performed en bloc with nephrectomy and with clear margins, cavectomy obviates the need for radiotherapy per protocol.

Coronary artery diseases after right ventricular outflow tract reconstruction surgery

Abstract Background The occurrence of coronary artery disease (CAD) is unknown to date in patients who have undergone the right ventricular outflow tract (RVOT) reconstruction surgery for congenital heart disease using a bioprosthetic valve or conduit. Purpose We present the incidence and outcomes of CAD in patients who underwent RVOT reconstruction surgery in a single tertiary center. Method From April 1986 to February 2019, 544 patients underwent Rastelli operation or pulmonary valve replacement for conotruncal anomalies at the Seoul National University Children's Hospital in Korea. The patient's medical records and imaging findings were analyzed retrospectively. Results Significant coronary stenosis or occlusion were observed in 19 patients (3.5%) after RVOT reconstruction surgery. Their underlying diseases were pulmonary atresia in 8, tetralogy of Fallot in 3, double outlet right ventricle with pulmonary stenosis in 3, truncus arteriosus in 2, congenitally corrective transposition of great artery in 2, and congenital aortic stenosis in 1. Mechanism of CAD was compression of coronary artery by artificial conduit or valve in 10, intraoperative coronary injury in 7, and intramural course of coronary artery in 2 patients. The median number of RVOT reconstruction surgery before the diagnosis of CAD was 2 times (interquartile range: 2–3 times). The median age at diagnosis of CAD was 15 years (interquartile range: 9.5 - 25 years). The median time to detection of the CAD from the last RVOT reconstruction surgery was 9 years (interquartile range: 3.5–12.5 years). Involved coronary artery was right coronary artery (RCA) in 10, left anterior descending coronary artery (LAD) in 7, and left main coronary artery in 2 patients. Seven (36.8%) patients had underlying congenital coronary anomalies, such as single coronary artery, intramural course of the coronary artery, and anomalous origin of the coronary artery from an abnormal sinus. One patient died due to brain injury on extracorporeal membrane oxygenator after intraoperative coronary injury. Two patients with intramural course of coronary artery and one patient with high take-off of RCA which was compressed by adjacent calcified conduit underwent surgical repair of the CAD. One patient with recurrent ventricular tachycardia needed an implantable cardioverter-defibrillator. Nine patients are on medication for heart failure. Three patients with total occlusion of RCA or LAD showed well-developed collaterals from another normal coronary artery. Conclusion CAD after RVOT reconstruction surgery are not common but can be fatal. Because the clinical significance of CAD and long-term prognosis are not known yet, we need to closely track the patient after RVOT reconstruction surgery. Indications for the management of the CAD should be prepared to prevent sudden cardiac death, arrhythmia, and ventricular dysfunction in these patients. Funding Acknowledgement Type of funding source: None