Dovepress Inaccurate angiographic assessment of atherosclerosis intervention for cases in which the angiographic anatomy of the patient, especially when the left anterior descending artery the target vessel constitutes the critical point upon which the is involved. Hence, our case exemplifies that even reasonable joint therapeutic decision is based. opacification of the target vessel through collaterals, may be Coronary blood flow depends on the balance between misleading for the construction of a surgical plan, and most coronary artery perfusion pressure and flow resistance in the importantly, for final decision-making. coronary tree. The main limitation of coronary angiography is that collateral flow detection provides only an estimate Disclosure of the absolute collateral flow. A momentarily altered The authors report no conflicts of interest in this work. balance between vasodilatation and vasoconstriction in the infarct-related artery could affect and could be affected by the flow through collaterals, potentially leading to a false angiographic estimation of lumen characteristics. Antegrade flow and flow through collaterals are constantly under an active balance. There are at least two possible explanations for the observed discrepancy between the angiographic assessment of coronary collateral vessels and rest or stress myocardial perfusion. First, coronary angiography depicts only those epicardial collateral channels with a lumen diameter .100 µm,10 but the most numerous and probably most important subendocardial and intramural intercoronary channels,11 about 20 µm in diameter,12 are not visualized. Second, the development and visualization of collateral vessels depend, at least in part, on the transanastomotic pressure, and could have an additional effect on angiographic visualization of the main vessel, which remains frequently a major channel supporting myocardium perfusion distally to the blockage of the artery.13 Because angiography in this situation may be proved unreliable, noninvasive imaging techniques that may assist better image guidance during chronic total occlusion revascularization, such as computed tomography angiography and invasive high fidelity intracoronary imaging with optical coherence tomography, might be useful for studying the lumen of the target vessel and guiding therapy.14 Conclusion In conclusion, the degree of distal vessel filling, not only via collateral circulation, and the resulting angiographic estimation of lumen characteristics, may affect medical and surgical decisions potentially impacting on the outcome for Vascular Health and Risk Management Publish your work in this journal References 1. Ivanhoe RJ, Weintraub WS, Douglas JS Jr, et al. Percutaneous transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis, and long-term clinical follow-up. Circulation. 1992;85: 106–115. 2. Magro M, Garg S, Serruys PW. Revascularization treatment of stable coronary artery disease. Expert Opin Pharmacother. 2011;12: 195–212. 3. 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; 5:587–592. 4. Delacretaz E, Meier B. Therapeutic strategy with total coronary artery occlusions. Am J Cardiol. 1997;79:185–187. 5. Habib GB, Heibig J, Forman SA, et al. Influence of coronary collateral vessels on myocardial infarct size in humans. Results of phase I thrombolysis in myocardial infarction (TIMI) trial. The TIMI Investigators. Circulation. 1991;83:739–746. 6. Komaru T, Kanatsuka H, Shirato K. Coronary microcirculation: Physiology and pharmacology. Pharmacol Ther. 2000;86:217–261. 7. Gershlick T, Thomas M. PCI or CABG: Which patients and at what cost? Heart. 2007;93:1188–1190. 8. Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: A systematic review and meta-analysis. Am Heart J. 2010;160:179–187. 9. Leung WH, Lau CP. Effects of severity of the residual stenosis of the infarct-related coronary artery on left ventricular dilation and function after acute myocardial infarction. J Am Coll Cardiol. 1992;20: 307–313. 10. Gensini GG, Bruto da Costa BC. The coronary collateral circulation in living man. Am J Cardiol. 1969;24:393–400. 11. Gregg DE, Patterson RE. Functional importance of the coronary collaterals. N Engl J Med. 1980;303:1404–1406. 12. Di Carli M, Sherman T, Khanna S, et al. Myocardial viability in asynergic regions subtended by occluded coronary arteries: Relation to the status of collateral flow in patients with chronic coronary artery disease. J Am Coll Cardiol. 1994;23:860–868. 13. Traupe T, Gloekler S, de Marchi S, Werner G, Seiler C. Assessment of the human coronary collateral circulation. Circulation. 2010;122: 1210–1220. 14. Courtney B, Munce N, Anderson K, et al. Innovations in imaging for chronic total occlusions: A glimpse into the future of angiography’s blind-spot. Eur Heart J. 2008;29:583–593. Dovepress Vascular Health and Risk Management is an international, peer- reviewed journal of therapeutics and risk management, focusing on concise rapid reporting of clinical studies on the processes involved in the maintenance of vascular health; the monitoring, prevention and treatment of vascular disease and its sequelae; and the involvement of metabolic disorders, particularly diabetes. This journal is indexed on PubMed Central and MedLine. 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