Author + information
- Received June 5, 2013
- Accepted July 3, 2013
- Published online April 1, 2014.
- Gabriele L. Gasparini, MD∗ (, )
- Marco L. Rossi, MD and
- Patrizia Presbitero, MD
- ↵∗Reprint requests and correspondence:
Dr. Gabriele L. Gasparini, Department of Invasive Cardiology, Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano (Milan), Italy.
Chronic total occlusion (CTO) of a coronary artery promotes negative remodeling in distal reference segments by negative vascular wall remodeling and plaque growth. Restoring blood flow by recanalization potentially leads to positive vascular remodeling.
We present the case of a 53-year-old man, a heavy smoker with dyslipidemia, hypertension, and family history of cardiac disease, who underwent percutaneous coronary intervention (PCI) of a CTO of the proximal right coronary artery (Fig. 1A).
CTO recanalization was attempted via a retrograde approach through a septal collateral (Figs. 1B to 1D). PCI was successful with implantation of 1 drug-eluting stent, 3.0 × 38 mm, in the ostio-proximal segment (Figs. 2A to 2C). At the end of the procedure, the angiography showed Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, with evidence of a severe and diffuse distal bed disease (Fig. 2D, Online Video 1). A 6-month angiographic follow-up showed a significant improvement in the diameter of the distal vessel, without evidence of stenotic lesions (Fig. 3, Online Video 2).
In the setting of CTOs, we have learned not to overtreat distal lesions, particularly small vessels; the distal bed disease, which has been chronically underperfused, tends to be overestimated, and the vessel frequently vasodilates and remodels with restoration of antegrade flow, as previously shown.
Few data have been published to investigate the role of blood flow restoration in the remodeling process (1). Galassi et al. (2) have suggested that the improvement of distal vessel diameter size detected at follow-up after CTO recanalization can theoretically be explained by 3 different mechanisms: 1) impaired endothelium-dependent and/or -independent vasomotion immediately after CTO recanalization (hibernated vascular wall) and/or an intense vasoconstriction that improves at follow-up; 2) positive remodeling; or 3) a combination of both.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 5, 2013.
- Accepted July 3, 2013.
- American College of Cardiology Foundation