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(Circulation. 1995;91:2113-2114.)
© 1995 American Heart Association, Inc.

Articles

Total Occlusions

The View of an Optimist

Spencer B. King, III, MD

From Emory University School of Medicine, Atlanta, Ga.

Correspondence to Spencer B. King III, MD, Department of Medicine (Cardiology), Emory University School of Medicine, Andreas Gruentzig Cardiovascular Center, 1364 Clifton Rd NE, Suite 7606, Atlanta, GA 30322.

	Introduction

 
The problem of restenosis is an important consideration any time angioplasty is contemplated. When the artery to be dilated is totally occluded, the restenosis rate is highest. As we showed in a large series of patients with chronically occluded arteries treated in the 1980s,¹ although approximately half of arteries that were successfully dilated exhibited restenosis, fewer than 20% progressed to total reocclusion.

The study by Violaris and coworkers² in this issue of Circulation reaffirms these findings in a large series with several new important characteristics: (1) there is a control group of patients with stenoses who are undergoing the same measurements; (2) the measurements performed are quantitative angiographic ones performed in a core laboratory; and (3) there is a high reangiogram rate due to the fact that the patients were enrolled in randomized clinical trials. The selection of these patients for clinical trials may have resulted in a somewhat lower restenosis rate than previously reported, since patients selected for the trials met certain clinical and anatomic entry criteria.

The authors offer several explanations for a higher reocclusion rate for totally occluded arteries and admit that all are speculative. These explanations are unmeasured hematologic factors; the morphology of the totally occluded lesions, which remains unknown; vasoconstriction occurring to a differential degree in postdilation patients; and differences in local flow dynamics due to differences in reference artery size and reference lesion diameter.

A major potential contributor to the reocclusion rate, however, was not discussed. It is assumed that the collateral circulation in . . . [Full Text of this Article]