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PubMed1990

Coronary sinus pressure has a direct effect on gradient for coronary perfusion.

In previous work from this laboratory we demonstrated that the coronary pressure-flow relationship exhibits a zero pressure intercept in the absence of the influence of the collateral circulation. In the present study we determined the effect of varying coronary sinus pressures on coronary perfusion. Specifically, we investigated whether coronary flow would cease when the coronary inflow pressure equaled the coronary sinus pressure. The study was performed while inflow perfusion pressure to all coronary vessels was changed simultaneously in order to reduce the influence of the collateral circulation while coronary sinus outflow was measured. Coronary pressure-flow relationships were obtained for coronary sinus pressures of 0, 10, and 20 mmHg. The results demonstrate a strong correlation between perfusion pressure and coronary sinus pressure (r2 = 0.994 +/- 0.001), which passed through the origin. We conclude that coronary sinus pressures between 0 and 20 mmHg have a direct influence on coronary perfusion.

Animals↗

PubMed1992

Long-term effects of percutaneous laser balloon ablation from the canine coronary sinus.

BACKGROUND: Radiofrequency catheter ablation of left-sided accessory pathways is becoming the first line of therapy for patients with symptomatic Wolff-Parkinson-White syndrome. Nevertheless, alternative ablation techniques merit development, at least as supplementary modalities for cases in which conventional ablation approaches may prove unsuccessful. We recently reported the short-term results with transcatheter laser balloon ablation from the coronary sinus in a canine model, proving that the procedure is feasible for the potential ablation of left-sided accessory pathways. We now report the effects of percutaneous transcatheter laser balloon ablation in a chronic canine model. METHODS AND RESULTS: Twenty adult mongrel dogs were studied. After baseline coronary arteriography, left ventriculography, and coronary sinus angiography were obtained, 15 dogs received two or three consecutive laser doses from the coronary sinus of 30-40 W for 15-30 seconds, for a total cumulative energy of 1,200-2,400 J. The five remaining animals underwent a procedure consisting of balloon sham inflation without laser exposure and served as controls. After a mean follow-up of 6 weeks, the angiographic procedures were repeated, and the animals were killed. The mean extent of the fibrotic lesion was 15 mm long, 6 mm wide, and 4.5 mm deep and involved the coronary sinus wall, atrium, and, frequently, the summit of the posterior left ventricular wall. Six animals (four in the study group and two in the control group) showed asymptomatic narrowing of the coronary sinus lumen but always with total angiographic reconstitution due to extensive collateral circulation. The circumflex artery and mitral valve were intact angiographically and histologically in all animals. CONCLUSIONS: Percutaneous transcatheter laser balloon ablation via the coronary sinus produces a lesion that may be anatomically well suited for left-sided accessory pathway ablation. Although coronary sinus narrowing may occur, adverse physiological effects are unlikely due to the development of extensive collateral circulation. Systematic clinical studies of this new approach to catheter ablation appear warranted.

Animals↗

PubMed1997

[Right-sided intrathoracic bypass grafting for a coarctation of the aorta in an advanced aged woman].

A sixty-two years old woman with a successful bypass grafting for coarctation of the thoracic aorta (Co-A) is presented. She has been suffering from hypertension since her thirties. Preoperative cardiac catheterization demonstrated Co-A with a pressure gradient of 100 mmHg. Angiography revealed the hypoplastic aortic arch with marked calcification and well developed collateral circulation. Right-sided intrathoracic bypass grafting using a 16 mm woven Dacron graft was placed between the ascending and descending aorta via a right sixth intercostal space. The patient had a good postoperative course with reduced pressure gradient of 10 mmHg. We recommend this procedure to be a safe and simple technique that can avoid injury to the collateral circulation to our knowledge, this is the most aged patient who underwent a successful surgical treatment for the Co-A in Japan.

Aorta↗

PubMed2003

Hypothermic circulatory arrest for the surgical treatment of complicated adult coarctation of the aorta.

OBJECTIVES: This study was designed to evaluate the surgical treatment of recurrent coarctation by a new technique. BACKGROUND: Recurrent coarctation either from aneurysm or recurrent constriction is a difficult problem in the adult because of the possible interruption of important collateral circulation. METHODS: We reviewed four patients who underwent recurrent coarctation surgery with the use of deep hypothermic circulatory arrest (HCA). RESULTS: All four patients survived. Deep HCA facilitated precise surgical resection and there was no postoperative paraplegia, stroke, or myocardial infarction. CONCLUSIONS: Deep HCA and resection and grafting of the coarctation is indicated for complicated adult coarctations, particularly when the collateral circulation is in doubt.

Adult↗

PubMed1990

[Maximal values of serum creatine phosphokinase and its myocardial fraction in acute myocardial infarct. Correlation with a previous history of ischemic cardiopathy].

OBJECTIVE: To evaluate the importance of preinfarction angina as a determinant of infarct size. DESIGN: Retrospective study of patients (pts) with acute myocardial infarction (AMI). SETTING: Patients admitted to an Intensive Care Unit of a University Hospital. PATIENTS: The study concerns 224 pts, 161 men women, aged 63.09 +/- 11.92 years, who did not receive thrombolytic or intravenous beta-blocking therapy and in whom it was possible to establish the presence or absence, of previous ischemic heart disease. METHODS: Patients, were divided in 2 groups: A (1st AMI, 172 dts - 123 M, 49 F) and B (2nd AMI, 52 dts - 38 M, 14 F). These groups were subdivided according the presence of preinfarction angina (A1, B1) or its absence (A2, B2). The infarct size was evaluated by peak values of CK/CKMB. RESULTS: Group A: CK/CKMB--959/101; Group B: CK/CKMB--742/77 (p-NS). Subgroups--A1: CK/CKMB--1143/118; A2: CK/CKMB--725/78 (p less than 0.001); B1: CK/CKMB--635/59; B2: CK/CKMB--818/88 (p-NS). The analysis of CK/CKMB values distribution, according to the affected cardiac wall, has shown an identical correlation. CONCLUSION: 1--The larger infarct size in subgroup A1 (1st AMI without angina) suggests a protective effect by collateral circulation in subgroup A2 (1st AMI with angina). 2--The larger infarction (although not significantly) in group A (1st AMI), correlates with less viable muscle in group B (2nd AMI). 3--The higher values of CK/CKMB in group B2 (2nd AMI with angina) can be expected given the presence of residual ischemia. 4--The absence of the protective role by collateral circulation in patients of subgroup A1 (1st AMI without angina) suggests for them a stronger indication for thrombolytic therapy.

Aged↗

PubMed1997

[Arterial dominance of the hand].

Arterial dominance in the hand was studied in 164 hands using digital pulse electronic oscillography (DPEO) and the Allen test. It was seen that the radial artery more frequently delivered the main blood supply to the digits (radial-ulnar dominance 12.8: 4.2%). The situation where no collateral circulation is present deserves special attention (absolute dominance). This was observed in 3% of the cases for the radial and in 1.2% for the ulnar artery. The Allen test was found useful in detecting ulnar artery dominance for the radial artery, however, false negative results may be obtained. In addition, 29 hands with a thrombosed radial artery were studied. No collateral circulation other than from the ulnar artery could be demonstrated. Since dominance of the ulnar artery is less common and can be reliably assessed with the Allen test, a forearm flap based on the ulnar artery appears to be safer than a radial forearm flap.

Female↗

PubMed1978

Intermittent claudication in the foot and Buerger's disease.

The objective of this investigation was to study the pathogenesis of intermittent claudication in the foot and to determine whether it could be used as a diagnostic manifestation of Buerger's disease. In 30 limbs with foot claudication and 20 limbs without foot claudication, systolic pressures at various levels of the leg were measured by a photoelectric technique, and the significance of collateral circulation in the foot on the development of claudication was studied. Although there was a significant difference between blood pressures at the foot and toe, considerable overlapping was seen between the two groups. This finding might indicate that muscle circulatory insufficiency in limbs with foot claudication results from occlusion of the nutrient arteries supplying the plantar muscles as well as poor collateral circulation in the foot. Hospital records of 48 patients with foot claudication were reviewed and the question of whether these patients could be diagnosed as having Buerger's disease was discussed. On the basis of clinical findings and arteriographic appearances, the diagnosis of Buerger's disease was made in all patients except one with hypercholesteraemia. From the results obtained here, foot claudication could be considered to be almost specific to Buerger's disease and a useful guide in the clinical diagnosis of this disease.

Adult↗

PubMed1996

[Myocardial infarction in patients with single-vessel disease: are there clinical or angiographic markers of viability?].

OBJECTIVE: To assess whether some of the clinical and angiographic variables usually associated with the severity of coronary artery disease could be considered as markers of viability after myocardial infarction. PATIENTS: We studied 41 patients with previous Q wave infarction and single-vessel coronary artery disease. METHODS: Patients were studied with thallium-201 SPECT, two imaging acquisitions were performed: stress and reinjection three to four hours later under nitroglycerin effect. Perfusion and viability were compared to clinical and angiographic variables, including the degree of patency and colateralization. RESULTS: In the infarct related area, 66 % of the 177 perfusion defects were considered reversible (definite in 40 %). In patient analysis, 28 patients were considered as having reversibility (18 with definite and 10 with possible reversibility). None of the clinical or stress test variables were significantly associated with reversibility; all these variables had extremely poor negative predictive values and only stress-induced ST depression had a reasonable positive predictive value (85 %). There was no association between TIMI grade and reversibility. In segments supplied by a TIMI 0 artery, a higher rate of fixed perfusion defects was associated with the absence of collateral circulation (75 % vs 22%; p < 0.013). Furthermore, severe impairment of contractility did not predict absence of viability, we identified as viable 55 % of akinetic segments and 29 % of segments classified angiographically as aneurysm. CONCLUSIONS: These data suggest that common clinical and angiographic markers of severity of coronary artery disease are not useful in the detection of viable myocardium after myocardial infarction. Collateral circulation to occluded arteries was associated with viability, but its absence did not exclude it. Viability detection with appropriated tests, namely stress reinjection thalium scintigraphy should perhaps be considered as a routine procedure after myocardial infarction, especially when interventional therapy is to be considered.

Adult↗

PubMed1989

Reversal of rest asynergy during exercise in patients with coronary artery disease.

The diagnosis of ischemic heart disease by radionuclide ventriculography (RNV) is performed on the basis of an abnormal response of the left ventricular ejection fraction and the occurrence, or aggravation, of regional wall motion abnormality during exercise. However, the abnormal wall motion observed by RNV at rest is improved in some patients with coronary artery disease during exercise. We examined the clinical features of such patients who showed a paradoxical response of regional wall motion. The left ventricle was divided into 4 segments: anteroseptal, apical, inferior and posterolateral. The degree of wall motion of each segment was classified into 5 grades and scored according to a 5 point system: 4 = normokinesis, 3 = hypokinesis, 2 = severe hypokinesis, 1 = akinesis and 0 = dyskinesis. The wall motion score (WMS) was calculated as the sum of each segment score. If the WMS increased by 2 points or more during exercise, the case was defined as having shown significant improvement of wall motion. Improvement in WMS was found in 26 (12%) of 209 serial patients who underwent exercise RNV, exercise thallium myocardial scintigraphy and coronary angiography. Clinically, half of these patients had a variant form of angina pectoris. With respect to coronary lesions in the segments with reversible asynergy, 12 patients had 0 vessel disease, 8 had lesions with stenosis of less than 75% and 3 showed an adequate collateral circulation. Redistribution found on the exercise thallium myocardial scintigram at the same sites of improved wall motion was identified in only 1 patient. An analysis of patients with paradoxical improvement of wall motion during exercise suggests the involvement of coronary spasm, an improvement of coronary flow reserve, such as could be produced by regression or recanalization of the main lesions, or establishment of significant collateral circulation.

Coronary Angiography↗

PubMed1995

Effect of aberrant hepatic arterial anatomy on tumour response to hepatic artery infusion of floxuridine for colorectal liver metastases.

Regional hepatic artery infusion of colorectal liver metastases produces the highest reported treatment response. The effect of variation in hepatic artery anatomy on tumour response to regional floxuridine (FUdR) was studied. Aberrant hepatic arterial anatomy occurred in 13 of 74 patients (18 per cent) who underwent cannulation of the hepatic artery and infusion of FUdR for colorectal liver metastases. The non-dominant hepatic artery was ligated and the dominant artery cannulated in those with aberrant anatomy. Despite evidence of a collateral circulation to the non-dominant area of the liver in these patients, there was no significant reduction in median tumour volume with treatment (before treatment 214 ml, after treatment 339 ml). By contrast, there was a significant (P < 0.001) decrease in median tumour volume (before treatment 329 ml, after treatment 148 ml) in those with normal anatomy. Delivery of FUdR to metastases via an intrahepatic collateral circulation was not as effective as through a main hepatic artery.

Colorectal Neoplasms↗

PubMed1970

Criteria for internal mammary artery implantation based on cine coronary arteriography.

Preoperative coronary arteriograms were correlated, in a group of 50 patients, with left internal mammary angiograms obtained from 11 to 32 months, with a mean of 17 months, after mammary artery implantation. In all patients in whom the internal mammary artery was patent and considered functional with good angiographic opacification of the anterior descending coronary artery, the preoperative coronary angiogram showed total or subtotal obstruction of the latter vessel, with indirect evidence of decreased flow and pressure distal to the obstruction. This evidence was provided by the presence of a collateral circulation or, in a few cases of subtotal obstruction, delayed opacification of the vessel distal to the obstruction.In patients in whom the internal mammary artery was patent but showed no anastomotic connection with the anterior descending coronary artery or only opacification of small coronary branches, the degree of coronary obstruction was, in most cases, less than 90% of the lumen of the coronary artery in the absence of any collateral circulation or delayed opacification of the vessel distal to the obstruction.Occlusion of the internal mammary artery was seen as often in the presence of total or subtotal obstructions as with lesser degrees of anterior descending coronary artery obstruction, and is believed unrelated to the degree of pre-existing coronary artery disease.Successful internal mammary artery implantation can be related to specific coronary angiographic patterns recognizable before operation; these may serve as reliable criteria for the selection of patients.

Arteriovenous Anastomosis↗

PubMed1999

Cardioprotective effects of adenosine transport inhibition during reversible ischaemia in patients with coronary artery disease.

BACKGROUND: Adenosine plays a major role in protecting ischaemic myocardium and may potentiate ischaemic preconditioning. Nucleosine transport inhibition may enhance these favourable effects. DESIGN: Randomized, double blind, placebo controlled study, to investigate the haemodynamic and cardioprotective effects of nucleoside transport inhibition during ischaemia in patients with coronary artery disease. PATIENTS AND METHODS: Elective left anterior descending (LAD) coronary angioplasty was used to produce reversible ischaemia in 24 patients with stable angina and a single LAD lesion. They were randomized to receive either the nucleoside transport inhibitor draflazine or placebo. The study medication was infused between the 2nd and 3rd balloon inflation. The primary endpoint was ischaemia-induced wall motion abnormalities as measured by left septal echo amplitude, which was plotted against time to produce an area under the curve. RESULTS: No differences were observed in the systemic haemodynamics or the myocardial collateral circulation of the two groups. The ischaemia-induced regional wall motion abnormalities improved significantly after draflazine, while no difference was observed in the placebo group. This improvement was even more pronounced in patients with low caffeine levels compared with those with high caffeine levels. CONCLUSIONS: Draflazine, in the dose and route used, is associated with a significant improvement in regional myocardial function of the ischaemic area, without affecting systemic or collateral circulation, when compared with placebo. This implies that draflazine has a cardio-protective effect in ischaemic myocardium. High caffeine blood levels reduce these effects.

Journal Article↗

PubMed2000

Factors predicting mortality in patients after myocardial infarction caused by left main coronary artery occlusion: significance of ST segment elevation in both aVR and aVL leads.

Acute left main coronary artery obstruction is rare and most patients in this clinical setting die of sudden death or cardiogenic shock. During the past 8 years, we encountered 13 patients with acute myocardial infarction caused by total occlusion of the left main coronary artery (LMCA-AMI). Thus, we surveyed these patients, and attempted to elucidate helpful predictors related to the prognosis. Six of 13 patients with LMCA-AMI survived. Successful left coronary artery dilatation was achieved in all survivors (group S), and in 5 (71%) non-survivors (group non-S). The age was not different between the two groups. A past history of angina was confirmed in 83% of group S. while only in 29% of group non-S. Clinical findings such as time of onset of AMI, interval from the AMI onset to admission, elapsed period from the AMI onset to recanalization of LMCA and the value of CK on admission were not different between the two groups. However, cardiogenic shock occurred in only 1 patient (17%) in group S compared with 5 patients (71%) in group non-S. As emphasized in the literature, good collateral circulation to the left anterior descending artery was observed in 5 patients (83%) in group S, while not observed in group non-S. Electro cardiographically, ST elevation in the aVR lead was very characteristic. This finding was confirmed in 69% of the total patients. Noticeably, 5 out of 6 non-survivors (83%) showed ST elevation not only in leads aVR but also in the aVL lead. In addition to the absence of collateral circulation, this electrocardiographic finding, which obviously indicates the presence of extensive myocardial ischemia in the diseased heart, is a simple and important predictor suggesting a poor prognosis in LMCA-AMI patients.

Angioplasty, Balloon, Coronary↗

PubMed1999

Isolated inferior mesenteric artery revascularization for chronic visceral ischemia.

PURPOSE: Complete visceral artery revascularization is recommended for the treatment of chronic visceral ischemia. However, in rare cases, it may not be possible to revascularize either the celiac or superior mesenteric (SMA) arteries. We have managed a series of patients with isolated revascularization of the inferior mesenteric artery (IMA) and now report our experience gained over a period of three decades. METHODS: Records were reviewed from 11 patients with chronic visceral ischemia who underwent isolated IMA revascularization (n = 8) or who, because of failure of concomitant celiac or SMA repairs, were functionally left with an isolated IMA revascularization (n = 3). All the patients had symptomatic chronic visceral ischemia documented with arteriography. Five patients had recurrent visceral ischemia after failed visceral revascularization, and two patients had undergone resection of ischemic bowel. The celiac or the SMA was unsuitable for revascularization in five cases, and extensive adhesions precluded safe exposure of the celiac or the SMA in five cases. IMA revascularization techniques included: bypass grafting (n = 4), transaortic endarterectomy (n = 4), reimplantation (n = 2), and patch angioplasty (n = 1). RESULTS: There was one perioperative death, and the remaining 10 patients had cured or improved conditions at discharge. One IMA repair thrombosed acutely but was successfully revascularized at reoperation. The median follow-up period was 6 years (range, 1 month to 13 years). Two patients had recurrent symptoms develop despite patent IMA repairs and required subsequent visceral revascularization; interruption of collateral circulation by prior bowel resection may have contributed to recurrence in both patients. Objective follow-up examination with arteriography or duplex scanning was available for eight patients at least 1 year after IMA revascularization, and all underwent patent IMA repairs. There were no late deaths as a result of bowel infarction. CONCLUSION: Isolated IMA revascularization may be useful when revascularization of other major visceral arteries cannot be performed and a well-developed, intact IMA collateral circulation is present. In this select subset of patients with chronic visceral ischemia, isolated IMA revascularization can achieve relief of symptoms and may be a lifesaving procedure.

Angioplasty↗

PubMed1979

[Congenital arteriopathies and Leo Buerger's disease].

A homogenous series of 7 consecutive cases of Buerger's disease were investigated and the congenital malformations of the upper and lower limb arterial trunks were classified. These malformations constitute the anatomical basis of Buerger's disease and define an autonomous disease entity. Total supra-malleolar interruption of the main lower limb arteries either by triple vessel agenesis or, more rarely, by femoro-popliteal or popliteal and tibio-peronal agenesis was observed. The appearances of the collateral circulation, already established in utero, are characteristic with long axial spiral-shaped arteries and dependant arterioles maintaining a precarious supply to the distal tissues which may be adequate for many years. The nautral history of the disease is directly related to the malformation of the congenital arterial system of the limbs. Proximal arterial malformative occlusion is the cause of early, inevitable trophic lesions; the spiral-shaped arteries and distal arterioles, which represent the maximal embryonic collateral circulation, limit the area of necrosis and favour healing.

Adult↗

PubMed2001

[Circulation support in left thoracotomy for descending thoracic aorta diseases in pediatric patients].

BACKGROUND: Complications of surgery of the descending thoracic aorta could include neurological problems such as paraparesis and paraplegia. Intestinal ischemia and acute renal failure could occur, too. During the cross-clamping time, the perfusion of the distal aorta by means of extracorporeal circulatory assistance can be useful to protect the spinal cord and the splanchnic organs and to reduce the incidence of these untoward events. The aim of this study was to verify the efficacy and suitability of this type of circulatory assistance in a pediatric age group. METHODS: From January 1996 to March 2000, in the Pediatric Cardiac Surgery Department of the Gaslini Institute (Genoa, Italy), 6 patients (mean age 39 months, mean weight 14.4 kg) were treated using extracorporeal circulatory assistance through the left thoracotomy. Indications for surgery included the removal of a migrated device previously inserted in order to close a patent ductus arteriosus in 1 patient, recurrent coarctation in 2 patients, and native coarctation with a poor collateral circulation in 3 patients. RESULTS: The early and late mortality rates as well as the morbidity rates (both neurological and splanchnic) were nil. CONCLUSIONS: Extracorporeal circulatory assistance can be helpful in pediatric patients and it can prevent neurological and renal injuries in cases of a) coarctation of the aorta with a poor collateral circulation and low distal pressure (< 40 mmHg during aortic occlusion); b) recoarctation with complex anatomy; c) other pathologies requiring prolonged descending thoracic aorta cross-clamping.

Aorta, Thoracic↗

PubMed2004

Intraoperative ischemia and long-term events after minimally invasive coronary surgery.

BACKGROUND: Concern has been raised about the effects of prolonged left anterior descending (LAD) artery occlusion during minimally invasive direct coronary artery bypass graft surgery (MIDCABG). We sought to assess the impact of myocardial dysfunction during MIDCABG on long-term outcome and the protective role of collateral circulation on myocardial ischemia. METHODS: Myocardial function was evaluated in 92 patients by intraoperative transesophageal echocardiography during MIDCABG. RESULTS: Wall motion score index increased during LAD occlusion (p < 0.00l) and reverted after LAD reopening (p < 0.001 versus occlusion and p = not significant versus baseline). The change in wall motion score index (occlusion versus baseline) was higher in patients with multivessel disease (p < 0.05) and in patients with LAD Thrombolysis in Myocardial Infarction study classification flow grade 2 or less without collateral circulation (p < 0.05). Myocardial stunning was documented in 12 patients (13%). The 5-year adverse event rate (including death, myocardial infarction, and revascularization) was 12%. By multivariate Cox regression analysis, multivessel disease, but not perioperative ischemia or stunning, was the only predictor of event-free survival. CONCLUSIONS: During MIDCABG anterior wall dysfunction is transient, with prompt recovery after completion of the anastamosis in most cases; myocardial stunning can be documented in a minority of patients. Flow either antegrade or retrograde in the LAD territory plays a protective role against the development of ischemia. Multivessel disease, but not perioperative ischemia or stunning, predicts long-term event-free survival.

Aged↗

PubMed2001

Entry sites for coronary angiography and therapeutic interventions: from the proximal to the distal radial artery.

When coronary angiography was introduced at the Montreal Heart Institute, Montreal, Quebec, in 1964, a cutdown arteriotomy of the proximal radial artery 2 to 3 cm distal to its origin was selected as the standard access site used instead of the brachial artery approach described by Mason Sones Jr. The risk of symptomatic local thrombosis requiring surgical care appeared less at that site on the basis of collateral circulation to the hand by the ulnar and palmar arches. Attempts to replace the time-consuming cutdown arteriotomy by a percutaneous transarterial approach led successively to the axillary, femoral and brachial arteries and finally, over 20 years later, to the radial artery. The transradial approach for diagnostic angiography, first reported in 1989 and adapted by others several years later for angioplasty, is now used in over 44 countries. The only contraindication for this approach is the rare, inadequate ulnar artery collateral circulation to the hand, clinically recognized by an abnormal Allen test. The transradial approach is advantageous in that there is an easier and safer postprocedural hemostasis at the entry site, it is preferred by patients and ambulation within hours is compatible with an outpatient procedure.

Blood Vessel Prosthesis Implantation↗