Chronic total coronary occlusions, distal collateral supply and implications of recanalisation

Ladwiniec, Andrew

Medicine
June 2016

Thesis or dissertation


Rights
© 2016 Andrew Ladwiniec. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder.
Abstract

The optimal treatment for patients with a chronic total coronary occlusion (CTO) is controversial, both in terms of the decision whether to revascularise and with respect to the physiological effect of recanalisation on revascularisation strategy.

Physiological lesion assessment in the form of fractional flow reserve (FFR) is now well established for the purpose of guiding multi-vessel revascularisation. CTOs are frequently associated with multi-vessel disease and the collateral dependent myocardium distal to the occlusion is often supplied by a collateral supply from another epicardial coronary. The haemodynamic effect of collateral donation upon collateral donor vessel flow may have important implications for the vessel’s FFR; rendering it unreliable at predicting ischaemia should the CTO be revascularised. These haemodynamic changes along with the changes in the target vessel after recanalisation of the occlusion are not well described.

The ability to form a functional collateral supply varies considerably between individuals. As arteriogenesis is an endothelium dependent process we hypothesised that biomarkers of endothelial health might be associated with the degree of functional collateralisation measured invasively in the coronary vessel segment distal to a CTO.

In this series of studies, I first compare long-term outcomes between patients with a chronic total coronary occlusion treated electively by medical therapy or CTO PCI. I go on to study the haemodynamic changes associated with CTO PCI. Firstly, the associated changes in physiology in the non-CTO vessels and how these changes might influence best revascularisation strategy. Secondly, the haemodynamics in the recently recanalised CTO vessel and the effect that might have on physiological optimization of the PCI result. Finally, I compare coronary haemodynamics taken at the time of CTO PCI with biomarkers of endothelial health to investigate a link between their levels and degree of functional collateralisation. The over-arching goal of this thesis is to add to our understanding of how best to manage patients with a chronic total coronary occlusion.

Publisher
Hull York Medical School, The University of Hull and the University of York
Supervisor
Hoye, Angela
Sponsor (Organisation)
The Hull And East Riding Cardiac Trust Fund
Qualification level
Doctoral
Qualification name
MD
Language
English
Extent
7 MB
Identifier
hull:13583
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