Vascular Health and Risk Management Open Access Full Text Article Dovepress open access to scientific and medical research C A s e R e P O R T Angiographic estimation of atherosclerotic disease burden in a coronary artery fed by collaterals: a potential pitfall in decision for revascularization Grigorios Tsigkas Panagiota Mylona Periklis Davlouros Dimitrios Alexopoulos Cardiology Department, University Hospital of Patras, Patras, Greece Correspondence: Grigorios Tsigkas Patras University Hospital, Rion Patras 26500, Greece Tel +30 26 1099 9281 Fax +30 26 1099 2941 email gregtsig@hotmail.com Abstract: Despite the remarkable advances in revascularization strategies made during the last decade, a significant proportion of patients are excluded from either percutaneous coronary intervention or coronary artery bypass grafting because of unsuitable coronary anatomy. Diffuse severe coronary artery disease, small vessel caliber, chronic total occlusions, or extremely calcified vessels are frequent reasons for deferring revascularization with either percutaneous coronary intervention or coronary artery bypass grafting. We present a case concerning a middle-aged asymptomatic patient who was treated successfully with percutaneous coronary intervention due to a chronic total occlusion lesion of the left anterior descending artery. Coronary angiography is an inadequate method for the estimation of the burden of atherosclerotic disease in an artery fed by collaterals. Assessment of any residual antegrade flow, and ipsilateral and contralateral collateral filling of the segments distal to the occlusion with invasive or noninvasive techniques, could affect the appropriate decision-making by physicians. Keywords: collaterals, percutaneous coronary intervention, coronary artery bypass grafting, ischemia, revascularization, chronic total occlusion Introduction Diffuse severe coronary artery disease, small vessel caliber, chronic total occlusions, or extremely calcified vessels are frequent reasons for deferring revascularization with either percutaneous coronary intervention or coronary artery bypass grafting.1 Presumably, estimation of such angiographic characteristics in a culprit vessel with a proximal total occlusion is feasible only through a well developed collateral network. There is general agreement that optimal medical treatment is the cornerstone of coronary artery disease management. Meanwhile, there is no doubt that timely revascularization offers a benefit in controlling patients with severe symptoms and may also offer a survival benefit in patients with diffuse disease and diabetes.2 Known techniques and innovations are crucial if old, calcified, and long chronic total occlusions are to be recanalized, proceeding with percutaneous coronary intervention. On the other hand, coronary artery bypass grafting is the basic alternative for treatment of diffusely diseased vessels not amendable to percutaneous coronary intervention. We present a case concerning a middle-aged asymptomatic patient who was treated successfully with percutaneous coronary intervention due to a chronic total occlusion lesion of the left anterior descending artery, despite initial misleading angiographic images. submit your manuscript | www.dovepress.com Dovepress DOI: 10.2147/VHRM.S18483 Vascular Health and Risk Management 2011:7 165–167 © 2011 Tsigkas et al, publisher and licensee Dove Medical Press Ltd.This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 165