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The dynamics of the coronary collateral circulation

Nature Reviews Cardiology volume 11, pages 191–197 (2014)Cite this article

Subjects

Key Points

  • The coronary collateral circulation protects the heart from myocardial ischaemia, and is associated with improved survival in patients with coronary artery disease

  • Collateral vessels are present at birth, develop throughout life, undergo positive remodelling (arteriogenesis) in the presence of a total or subtotal coronary occlusion, and usually regress with age

  • The myocardial protective effect of the collateral circulation is dynamic in nature, as collateral function can be modulated by several factors

  • Preconditioning, the injection of growth factors, and measures to prolong ventricular diastolic filling time all promote collateral vessel growth and remodelling

  • Collateral flow can be reduced and even reverted if atherosclerosis progresses in the donor artery, a process called the 'collateral steal'

  • Re-establishment of the antegrade flow in the recipient artery induces a derecruitment of collaterals, thus exposing the recipient territory to myocardial ischaemia in cases of sudden coronary occlusion

Abstract

Coronary collaterals are present at birth, with wide interindividual variation in their functional capacity. These vessels protect jeopardized myocardium, and the number of collaterals and the extent of their coverage are associated with improved survival in patients with coronary heart disease. The collateral circulation is not a permanent set of structures, but undergoes dynamic changes with important consequences for cardioprotection. If a severe atherosclerotic lesion develops in an artery supplying tissue downstream of a total occlusion through collateral blood flow, pressure gradients across the collateral bed change. The result is that some of the collateral flow previously supplying the perfusion territory of the totally occluded artery is redirected to the perfusion territory of the donor artery, thus producing a 'collateral steal'. The collateral circulation can regress once antegrade flow in the main dependent artery is re-established, as occurs following the recanalization of a chronic total occlusion. The clinical benefits of coronary revascularization must be cautiously weighed against the risk of reducing the protective support derived from coronary collaterals. Consequently, pharmacological, gene-based, and cell-based therapeutic attempts have been made to enhance collateral function. Although such approaches have so far yielded no, or modest, beneficial results, the rapidly accruing data on coronary collateral circulation will hopefully lead to new effective therapeutic strategies.

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Figure 1: Arteriogenesis.
Figure 2: Epicardial collateral circulation.
Figure 3: Conditions that change collateral flow.

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Acknowledgements

During the production of this manuscript we witnessed the lost battle—fought with extreme dignity—of our beloved 32-year-old secretarial assistant Lodovica Ottavi against an incurable disease. We will always miss her.

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Authors and Affiliations

  1. Institute of Cardiology and Center of Excellence on Aging, Università degli Studi 'G. d'Annunzio' Chieti e Pescara, c/o Ospedale SS. Annunziata, Via dei Vestini, Chieti, 66100, Italy

    Marco Zimarino, Mariangela D'Andreamatteo & Raffaele De Caterina

  2. Interventional Cardiology, MedStar Washington Hospital Center, 110 Irving Street North West, Washington, 20010, DC, USA

    Ron Waksman & Stephen E. Epstein

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Contributions

M. Zimarino wrote the article, substantially contributed to discussion of content, reviewed and edited the manuscript. M. D'Andreamatteo researched data for the article. R. Waksman substantially contributed to discussion of content. S. E. Epstein wrote the article, substantially contributed to discussion of content, and reviewed the manuscript. R. De Caterina reviewed the manuscript before submission.

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Correspondence to Marco Zimarino.

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Zimarino, M., D'Andreamatteo, M., Waksman, R. et al. The dynamics of the coronary collateral circulation. Nat Rev Cardiol 11, 191–197 (2014). https://doi.org/10.1038/nrcardio.2013.207

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