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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 169-171

Coronary collateral connection score in chronic total coronary occlusion lesions in the view of ELShafey speculation


1 Cardiology Department of EL Menoufia University Hospital, Shebien EL Koom, Menoufia, Egypt
2 Department of Medicine, Catania University, Sicily, Italy

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. Wassam ELDin H ELShafey
Cardiology Department, EL Menoufia University Hospital, Shebien EL Koom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IHJI.IHJI_22_18

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  Abstract 

Human coronary collaterals are intercoronary communications that are believed to be present from birth. In the presence of chronic total coronary occlusions (CTO), a total occlusion of perceived or known duration of 3 months or longer is labeled as chronic occlusion. Recruitment of flow via these collateral anastomoses to the arterial segment distal to occlusion provides an alternative source of blood flow to the myocardial segment at risk. Although coronary angiography is the standard method to visualize collateral arteries, it has a limited resolution. The visible collaterals have a diameter from 0.3 up to 0.5mm, therefore arterioles <100 µm are unseen by the human eye. In addition, nitrates and adenosine allow a better visualization of collateral branches, exploiting their vasomotor properties. A reported quantitative angiographic analysis of collateral diameters on high-resolution cine films underscored the relevance of the collateral diameter for the collateral function. Aside from the complexity of this approach, its applicability to modern digital storage standards with lower resolutions is limited. ELShafey speculation is based on using a modified pattern of the inverted gray scale of cine angiograms for a better visualization of different ambiguity coronary artery lesions.

Keywords: Chronic total occlusion, coronary collateral score, inverted gray scale


How to cite this article:
ELShafey WH, Galassi AR. Coronary collateral connection score in chronic total coronary occlusion lesions in the view of ELShafey speculation. Indian Heart J Interv 2018;1:169-71

How to cite this URL:
ELShafey WH, Galassi AR. Coronary collateral connection score in chronic total coronary occlusion lesions in the view of ELShafey speculation. Indian Heart J Interv [serial online] 2018 [cited 2019 Mar 25];1:169-71. Available from: http://www.ihji.org/text.asp?2018/1/2/169/247446




  Introduction Top


Human coronary collaterals are intercoronary communications that are believed to be present from birth.[1] In the presence of chronic total coronary occlusions (CTO), a total occlusion of perceived or known duration of 3 months or longer is labeled as chronic occlusion.[2] Recruitment of flow via these collateral anastomoses to the arterial segment distal to occlusion provides an alternative source of blood flow to the myocardial segment at risk. This mitigates the ischemic injury. Clinical outcome of coronary occlusion, that is, severity of myocardial infarction/ischemia, impairment of cardiac function, and possibly survival, depends not only on the acuity of the occlusion, extent of jeopardized myocardium, duration of ischemia but also on the adequacy of collateral circulation. Adequacy of collateral circulation can be assessed by various methods. These coronary collateral channels have been used successfully as a retrograde access route for percutaneous recanalization of chronic total occlusions. Factors that promote angiogenesis and further collateral remodeling, that is, arteriogenesis have been identified.[3]

The anatomic collaterals pathway was first categorized by Levine[4] into 26 different types and summarized into four categories: septal collaterals, intra-arterial (bridging), epicardial collaterals with proximal takeoff (atrial branches), and epicardial collateral with distal takeoff. In case of coexisting collateral pathways, the one that first opacified the occluded epicardial segment was defined as the principal collateral.

In time, Rentrop et al.[5] proposed another classification that divided the collateral connections (CCs) into four groups according to the grade of occluded segment opacification: grade 0, no filling; grade 1, side branch filling of the artery to be dilated using collateral channels without epicardial segment visualization; grade 2, partial filling of the epicardial segment using collateral channel; and grade 3, complete filling of the epicardial segment of the artery being dilated using collateral channel.

Recently, Werner et al.[6] proposed an evaluation of the size of the CC diameter measured by three grades: CC0, no continuous connection between donor and recipient artery; CC1, continuous, threadlike connection; and CC2, continuous, small side branch-like size of the collateral throughout its course.

Although coronary angiography is the standard method to visualize collateral arteries, it has a limited resolution. The visible collaterals have a diameter from 0.3 up to 0.5mm, therefore arterioles <100 µm are unseen by the human eye. In addition, nitrates and adenosine allow a better visualization of collateral branches, exploiting their vasomotor properties. A reported quantitative angiographic analysis of collateral diameters on high-resolution cine films underscored the relevance of the collateral diameter for the collateral function. Aside from the complexity of this approach, its applicability to modern digital storage standards with lower resolutions is limited.[7]

ELShafey speculation[8] is based on using a modified pattern of the inverted gray scale of cine angiograms for a better visualization of different ambiguity coronary artery lesions. When applying this assumption with the help of one of the CTO interventional experts for revising cine angiograms of different cases candidate for retrograde revascularization approach. We showed, when traditionally marking a case to have CC grade 0, after meticulous revision by inverted gray scale with modified image contrast, many cases were upgraded to CC1 [Figure 1], [Figure 2] [Figure 3].
Figure 1: Right coronary total occlusion in the mid part with retrograde collaterals from left anterior descending in (A), no clear connections (CC0), whereas in (B), clear continuous connections (CC1)

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,
Figure 2: Right coronary total occlusion in the distal part with retrograde collaterals from left anterior descending (LAD) septal collaterals in (A), no clear connections (CC0), whereas in (B), clear continuous septal channel connecting LAD and posterior descending artery (CC1) and the wire was in a wrong channel

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,
Figure 3: Right coronary total occlusion in the distal part with retrograde collaterals from left anterior descending septal collaterals in (A), no clear connections (CC0), whereas in (B), clear continuous septal bifurcating channel connecting LAD and posterior descending artery (CC1)

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  Conclusion Top


Inverted gray-scale cine angiogram with some contrast image modification (ELShafey speculation) should be used in tackling chronic total occlusion, especially when deciding to revascularize using retrograde approach via CCs as it may help in better visualization of tiny channels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baroldi G, Mantero O, Scomazzoni G. The collaterals of the coronary arteries in normal and pathologic hearts. Circ Res 1956;1:223-9.  Back to cited text no. 1
    
2.
Di Mario C, Werner GS, Sianos G, Galassi AR, Büttner J, Dudek D, et al. European perspective in the recanalisation of chronic total occlusions (CTO): Consensus document from the EuroCTO Club. Eurointervention 2007;1:30-43.  Back to cited text no. 2
    
3.
Schaper W. Collateral vessel growth in the human heart. Role of fibroblast growth factor-2. Circulation 1996;1:600-1.  Back to cited text no. 3
    
4.
Levine DC. Pathways and functional significance of the coronary collateral circulation. Circulation 1974;1:831-7.  Back to cited text no. 4
    
5.
Rentrop KP, Cohen M, Blanke H, Phillips RA. Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects. J Am Coll Cardiol 1985;1:587-92.  Back to cited text no. 5
    
6.
Werner GS, Ferrari M, Heinke S, Kuethe F, Surber R, Richartz BM, et al. Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions. Circulation 2003;1:1972-7.  Back to cited text no. 6
    
7.
Rockstroh J, Brown BG. Coronary collateral size, flow capacity, and growth: Estimates from the angiogram in patients with obstructive coronary disease. Circulation 2002;1:168-73.  Back to cited text no. 7
    
8.
Wassam E.L.Hadad ELShafey. Applicability of ELShafey speculation for better visualization of a variety of ambiguous coronary artery lesions. IHJ CCR 2018;1:187-90.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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