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Total coronary arterial occlusion: real or apparent?
International
Journal of Cardiology,
235
25 (1989) 235-231
Elsevier CARD10 09681
Brief Reports
Total coronary arterial occlusion: real or apparent? A. Seth, R.A. Perry and M.F. Shiu University Department
of Cardiology,
Queen Elizabeth
Medical Centre, Birmingham,
U.K.
(Received 5 April 1989; revision accepted 11 May 1989)
We describe a case in which the angiographic appearance of total occlusion of the left anterior descending coronary artery was not due to a complete anatomical obstruction, but due to competitive and retrograde flow in the distal segment of the artery from collaterals via the contralateral vessel. This case has implications on our current practice and results of coronary angioplasty in total coronary arterial occlusion. Key words:
Total coronary
arterial
occlusion:
Coronary
Introduction The definition and classification of total occlusion of a coronary artery is, normally, based on angiographic appearances alone [1,2]. This may or may not reflect the true anatomical nature of the obstruction. We describe a case in which the angiographic appearance of total arterial occlusion was not due to an anatomical obstruction, but due to competitive and retrograde flow in the distal segment of the vessel from collaterals from contralateral vessel. Case Report A 63-year-old man underwent coronary angiography for effort angina. This demonstrated a proximal stenosis of 90% in the left anterior descending coronary artery, normal antegrade filling of a diagonal branch alone and faint delayed flow down the middle segment of the artery (Fig. 1A). Injection into the right coronary artery
Correspondence to: Dr. A. Seth, Dept. of Cardiology, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025. India.
0167-5273/89/$03.50
angioplasty
showed retrograde opacification of the distal segment of the anterior descending artery to its mid portion via extensive collateral vessels within the septum. The appearances were compatible with a total occlusion of the mid portion of the anterior descending artery. It was decided to dilate first the proximal stenosis and then the mid occlusion. A .018” high torque flexible wire was steered across the proximal stenosis. No obstruction was met by the wire in crossing the middle segment of the artery into its distal portion. A 3.00 mm balloon catheter was placed across the proximal stenosis. Distal pressure recorded through the tip of the balloon catheter was 52 mm Hg and pressure gradient across the stenosis was 44 mm Hg (Fig. 2A). The distal pressure fell only slightly to 46 mm Hg during inflation of the balloon (Fig. 2B). The balloon catheter was then brought back into the guiding catheter for a contrast injection, leaving the wire in the vessel. Apart from showing a satisfactory dilatation of the proximal stenosis, the injection demonstrated normal calibre of the remaining parts of the anterior descending artery with no lesion visible at the site of the presumed total occlusion (Fig. lB), even though no dilatation had been performed in the mid segment of the vessel. Angiography repeated in the right coronary artery showed disappearance of retrograde opacification of the distal part of the anterior descending artery.
0 1989 Elsevier Science Pub&hers B.V. (Biomedical Division)
236
Fig. 1. Left coronary angiogram in the left anterior oblique projection. A. Before angioplasty: proximal stenosis of the left anterior descending artery (thin arrow) and “apparent” total occlusion of its mid segment (broad arrow) beyond the diagonal branch. B. Normal antegrade opacification of the entire left anterior descending artery following successful dilatation of the proximal stenosis.
Discussion The the mid time
Fig. 2. Pressure recordings through the guiding catheter (proximal) and tip of the balloon catheter (distal) during angioplasty of the proximal left anterior descending artery stenosis, demonstrating only slight fall in distal pressure following balloon inflation. A. Crossing gradient = deflated balloon across stenosis. B. Balloon occlusion = inflated balloon across stenosis.
and
portion
slow
filling
antegrade
of the anterior
of angioplasty,
retrograde
distal pressure
faint
together of the distal
opacification descending
with part
beyond
artery
the demonstration of the artery
at the of follow-
ing injection into the right coronary artery, gave the impression of a “functional” total occlusion of the anterior descending artery beyond its diagonal branch. This total occlusion was spurious resulting from competitive retrograde flow in the distal segment from the extensive collaterals supplied by the right coronary artery at a pressure higher than that existing in the anterior descending artery. This resulted in preferential antegrade flow down the diagonal, giving the impression of total occlusion of the anterior descending artery beyond the diagonal branch. This case is unusual due to the fact that the “apparent” total occlusion was markedly distal to the severe stenosis, leading us to believe that a separate lesion existed in the middle part of the artery. Demonstration of the adequacy of the collateral supply is provided by the high distal occlusion pressure recordings during balloon inflation, which has been well correlated to the presence of very good collateral flow [31. The observations
from this case may partly
explain
237 the discrepancy in success rates between various studies of coronary angioplasty in “functional” total occlusions [1,4]. Where competitive retrograde filling is present, there is always the possibility that the appearances of “functional” total occlusion may not be due to anatomic occlusion at all, but appear so due to a water-shed phenomenon at a point of demarcation between the two sources of flow and pressure. Anatomical arrangements such as the presence of side branches in and around the water-shed zone, tend to facilitate such “apparent” total occlusions on the angiogram.
2 Keriakes DJ, Salmon MR. McAuley BJ. McAuley DB, Sheehan DJ, Simpson JB. Angioplasty in total coronary occlusion: experience in 76 consecutive patients. J Am Co11 Cardiol 1985;6:536-533. 3 Probst P, Zangl W, Pachinger 0. Relation of coronary arterial occlusion pressure during PTCA to presence of collaterals. Am J Cardiol 1985;55:1264-1269. 4 DiSciascio G, Vetrovec GW, Cowley MJ, Wolfgang TC. Early and late outcome of percutaneous transluminal coronary angioplasty for subacute and chronic total coronary occlusion. Am Heart J 1986;111:833-839.
References 1 Serruys PW, Umans V, Heyndrickx GR, et al. Elective PTCA of totally occluded coronary arteries not associated with acute myocardial infarction; short and long term results. Eur Heart J 1985;6:2-12.
lntermztional Elsevier CARD10
Journal of Cardiology,
25 (1989) 237-239
09682
Functional aortic atresia in congenitally corrected transposition KC. Chan, P. Da Costa and D.F. Dickinson Department
of Paediatric Cardiology, Killingbeck Hospital, Leeds, V. K.
(Received 10 April 1989; revision accepted 11 May 1989)
An infant with congenitally corrected transposition and severe regurgitation through the left atrioventricular valve presented with clinical and Doppler echocardiographic features of aortic atresia. This eventually proved to be functional. This clinical situation had not, to the best of our knowledge been previously reported before. Key words: Corrected transposition;
Functional aortic atresia
Introduction Functional pulmonary atresia has been reported in Ebstein’s malformation, congenital tricuspid regurgitaCorrespondence
UhI’s anomaly and transient tricuspid regurgitation of the newborn [l]. To our knowledge, however, functional aortic atresia has not been reported. We report here a case of congenitally corrected transposition (usual atrial arrangement with discordant atrioventricular and ventriculoarterial connexions) with
tion,
to: Dr. D.F. Dickinson, Dept. of Paediatric
Cardiology, Kiltingbeck Hospital, York Road, Leeds LS14
severe
6UQ, U.K.
valve resulting in functional
0167-5273/89/$03.50
regurgitation
0 1989 Elsevier Science Publishers B.V. (Biomedical Division)
through
the
left
atrioventricular
aortic atresia.
Journal of Cardiology,
235
25 (1989) 235-231
Elsevier CARD10 09681
Brief Reports
Total coronary arterial occlusion: real or apparent? A. Seth, R.A. Perry and M.F. Shiu University Department
of Cardiology,
Queen Elizabeth
Medical Centre, Birmingham,
U.K.
(Received 5 April 1989; revision accepted 11 May 1989)
We describe a case in which the angiographic appearance of total occlusion of the left anterior descending coronary artery was not due to a complete anatomical obstruction, but due to competitive and retrograde flow in the distal segment of the artery from collaterals via the contralateral vessel. This case has implications on our current practice and results of coronary angioplasty in total coronary arterial occlusion. Key words:
Total coronary
arterial
occlusion:
Coronary
Introduction The definition and classification of total occlusion of a coronary artery is, normally, based on angiographic appearances alone [1,2]. This may or may not reflect the true anatomical nature of the obstruction. We describe a case in which the angiographic appearance of total arterial occlusion was not due to an anatomical obstruction, but due to competitive and retrograde flow in the distal segment of the vessel from collaterals from contralateral vessel. Case Report A 63-year-old man underwent coronary angiography for effort angina. This demonstrated a proximal stenosis of 90% in the left anterior descending coronary artery, normal antegrade filling of a diagonal branch alone and faint delayed flow down the middle segment of the artery (Fig. 1A). Injection into the right coronary artery
Correspondence to: Dr. A. Seth, Dept. of Cardiology, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025. India.
0167-5273/89/$03.50
angioplasty
showed retrograde opacification of the distal segment of the anterior descending artery to its mid portion via extensive collateral vessels within the septum. The appearances were compatible with a total occlusion of the mid portion of the anterior descending artery. It was decided to dilate first the proximal stenosis and then the mid occlusion. A .018” high torque flexible wire was steered across the proximal stenosis. No obstruction was met by the wire in crossing the middle segment of the artery into its distal portion. A 3.00 mm balloon catheter was placed across the proximal stenosis. Distal pressure recorded through the tip of the balloon catheter was 52 mm Hg and pressure gradient across the stenosis was 44 mm Hg (Fig. 2A). The distal pressure fell only slightly to 46 mm Hg during inflation of the balloon (Fig. 2B). The balloon catheter was then brought back into the guiding catheter for a contrast injection, leaving the wire in the vessel. Apart from showing a satisfactory dilatation of the proximal stenosis, the injection demonstrated normal calibre of the remaining parts of the anterior descending artery with no lesion visible at the site of the presumed total occlusion (Fig. lB), even though no dilatation had been performed in the mid segment of the vessel. Angiography repeated in the right coronary artery showed disappearance of retrograde opacification of the distal part of the anterior descending artery.
0 1989 Elsevier Science Pub&hers B.V. (Biomedical Division)
236
Fig. 1. Left coronary angiogram in the left anterior oblique projection. A. Before angioplasty: proximal stenosis of the left anterior descending artery (thin arrow) and “apparent” total occlusion of its mid segment (broad arrow) beyond the diagonal branch. B. Normal antegrade opacification of the entire left anterior descending artery following successful dilatation of the proximal stenosis.
Discussion The the mid time
Fig. 2. Pressure recordings through the guiding catheter (proximal) and tip of the balloon catheter (distal) during angioplasty of the proximal left anterior descending artery stenosis, demonstrating only slight fall in distal pressure following balloon inflation. A. Crossing gradient = deflated balloon across stenosis. B. Balloon occlusion = inflated balloon across stenosis.
and
portion
slow
filling
antegrade
of the anterior
of angioplasty,
retrograde
distal pressure
faint
together of the distal
opacification descending
with part
beyond
artery
the demonstration of the artery
at the of follow-
ing injection into the right coronary artery, gave the impression of a “functional” total occlusion of the anterior descending artery beyond its diagonal branch. This total occlusion was spurious resulting from competitive retrograde flow in the distal segment from the extensive collaterals supplied by the right coronary artery at a pressure higher than that existing in the anterior descending artery. This resulted in preferential antegrade flow down the diagonal, giving the impression of total occlusion of the anterior descending artery beyond the diagonal branch. This case is unusual due to the fact that the “apparent” total occlusion was markedly distal to the severe stenosis, leading us to believe that a separate lesion existed in the middle part of the artery. Demonstration of the adequacy of the collateral supply is provided by the high distal occlusion pressure recordings during balloon inflation, which has been well correlated to the presence of very good collateral flow [31. The observations
from this case may partly
explain
237 the discrepancy in success rates between various studies of coronary angioplasty in “functional” total occlusions [1,4]. Where competitive retrograde filling is present, there is always the possibility that the appearances of “functional” total occlusion may not be due to anatomic occlusion at all, but appear so due to a water-shed phenomenon at a point of demarcation between the two sources of flow and pressure. Anatomical arrangements such as the presence of side branches in and around the water-shed zone, tend to facilitate such “apparent” total occlusions on the angiogram.
2 Keriakes DJ, Salmon MR. McAuley BJ. McAuley DB, Sheehan DJ, Simpson JB. Angioplasty in total coronary occlusion: experience in 76 consecutive patients. J Am Co11 Cardiol 1985;6:536-533. 3 Probst P, Zangl W, Pachinger 0. Relation of coronary arterial occlusion pressure during PTCA to presence of collaterals. Am J Cardiol 1985;55:1264-1269. 4 DiSciascio G, Vetrovec GW, Cowley MJ, Wolfgang TC. Early and late outcome of percutaneous transluminal coronary angioplasty for subacute and chronic total coronary occlusion. Am Heart J 1986;111:833-839.
References 1 Serruys PW, Umans V, Heyndrickx GR, et al. Elective PTCA of totally occluded coronary arteries not associated with acute myocardial infarction; short and long term results. Eur Heart J 1985;6:2-12.
lntermztional Elsevier CARD10
Journal of Cardiology,
25 (1989) 237-239
09682
Functional aortic atresia in congenitally corrected transposition KC. Chan, P. Da Costa and D.F. Dickinson Department
of Paediatric Cardiology, Killingbeck Hospital, Leeds, V. K.
(Received 10 April 1989; revision accepted 11 May 1989)
An infant with congenitally corrected transposition and severe regurgitation through the left atrioventricular valve presented with clinical and Doppler echocardiographic features of aortic atresia. This eventually proved to be functional. This clinical situation had not, to the best of our knowledge been previously reported before. Key words: Corrected transposition;
Functional aortic atresia
Introduction Functional pulmonary atresia has been reported in Ebstein’s malformation, congenital tricuspid regurgitaCorrespondence
UhI’s anomaly and transient tricuspid regurgitation of the newborn [l]. To our knowledge, however, functional aortic atresia has not been reported. We report here a case of congenitally corrected transposition (usual atrial arrangement with discordant atrioventricular and ventriculoarterial connexions) with
tion,
to: Dr. D.F. Dickinson, Dept. of Paediatric
Cardiology, Kiltingbeck Hospital, York Road, Leeds LS14
severe
6UQ, U.K.
valve resulting in functional
0167-5273/89/$03.50
regurgitation
0 1989 Elsevier Science Publishers B.V. (Biomedical Division)
through
the
left
atrioventricular
aortic atresia.