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Heart. 2007 April; 93(4): 487.
PMCID: PMC1861490

Dynamic collateral coronary circulation: angiographic evidence

A 54‐year‐old man was admitted to our cardiovascular department because of angina on effort (Canadian class II). Angina was characterised by marked variability of the threshold and occasional episodes of rest angina. He was hypertensive, was an ex‐smoker and had diabetes. In 1998, he had an inferolateral myocardial infarction and was administered medical treatment including aspirin and β‐blokers. He remained asymptomatic on medical treatment up to 6 months prior to admission, when he had recurrence of angina on effort in spite of medical treatment including aspirin, β‐blokers, sartanic and statin. During current hospital stay, an echocardiogram revealed mild impairment of left ventricular function (ejection fraction 45%), inferolateral akinesia and moderate mitral regurgitation. A dobutamine stress test showed viable myocardium in the akinetic region. The patient underwent coronary angiography, which revealed proximal occlusion of the left circumflex artery of small size, proximal occlusion of the right coronary artery (RCA) and normal left anterior descending artery (LAD). Mild opacification of distal RCA was noted through collateral circulation originating from the septal branches of LAD (panel A). Reopening of the RCA was then attempted using a bilateral femoral approach with cannulation of the RCA by a guiding catheter and of the left coronary artery by a diagnostic catheter. A Pilot 200 guidewire (Guidant Corp, Santa Clara, California, USA) and an over the wire balloon 1.5/20 mm (Maverick 2, Boston Scientific Scimed, Maple Grove, Minnesota, USA) were initially used. Immediately prior to wire advancement across the occlusion, re‐injection of the contrast medium into the RCA showed a striking improvement of collateral circulation from Rentrop class 1 to Rentrop class 3, and full opacification of posterior descending, posterolateral branch and distal part of the RCA near to the occlusion point (panel B). Notably, no intracoronary nitrates were administered due to low arterial pressure (90/60 mm Hg) since the start of the procedure. This sudden change of collateral function helped operators in wire advancement through the occlusion and entry in the distal true lumen. After multiple balloon dilatation and deployment of three drug‐eluting stents (Taxus, Boston Scientific, Natick, Massachusetts, USA), the RCA was reconstructed and angiographic result was optimal (panel C). Dynamic collateral coronary circulation in man has been previously demonstrated using non‐invasive techniques, and well explains the variability of anginal threshold on effort. This is the first angiographic documentation that collateral circulation in man can be extremely dynamic.dynamic.

figure ht96867.f1
Panel A Coronary angiogram in left anterior oblique view showing the proximal occlusion of the right coronary artery (RCA) and collateral circulation from septal branches of the left anterior descending artery (LAD), with mild opacification of the distal ...
figure ht96867.f2
Panel B Coronary angiogram in left anterior oblique view showing a sudden variation of collateral circulation to the distal right coronary artery (RCA), with good opacification of the RCA branches (Rentrop 3). White arrows point to the left anterior descending ...
figure ht96867.f3
Panel C Coronary angiogram in left anterior oblique view showing the final angiographic result after multiple drug‐eluting stent deployment.

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