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

Ladwiniec, Andrew


Andrew Ladwiniec


Angela Hoye


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.


Ladwiniec, A. (2016). Chronic total coronary occlusions, distal collateral supply and implications of recanalisation. (Thesis). Hull York Medical School, the University of Hull and the University of York. Retrieved from

Thesis Type Thesis
Deposit Date Jul 26, 2016
Publicly Available Date Feb 23, 2023
Keywords Medicine
Public URL
Additional Information Hull York Medical School, The University of Hull and the University of York
Award Date Jun 1, 2016


Thesis (7.8 Mb)

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

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