Incidence and treatment of 'no-reflow' after percutaneous coronary intervention

Robert N. Piana, George Y. Paik, Mauro Moscucci, David J. Cohen, C. Michael Gibson, Aaron D. Kugelmass, Joseph P. Carrozza, Richard E. Kuntz, Donald S. Baim

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Abstract

Background: Profound reduction in antegrade epicardial coronary flow with concomitant ischemia is seen occasionally during percutaneous coronary intervention despite the absence of evident vessel dissection, obstruction, or distal vessel embolic cutoff. In a prior small series of cases, this 'no- reflow' phenomenon appeared to be promptly reversed by the intracoronary administration of verapamil. Methods and Results: To further understand the prevalence of this syndrome and its responsiveness to the proposed therapy, we reviewed 1919 percutaneous interventions performed between January 1991 and April 1993. During the study period, 39 patients (2.0%) met our criteria for no reflow, 37 of whom were treated with intracoronary nitroglycerin followed by intracoronary verapamil and 2 of whom received intracoronary nitroglycerin alone. An additional 16 patients (0.8%) were given verapamil as part of the management of a flow-limiting dissection or distal embolus (mechanical obstruction). Intracoronary verapamil (50 to 900 μg, total dose) improved TIMI flow grade in 89% of no-reflow patients and markedly reduced the number of cineframes between contrast injection and opacification of a selected distal landmark (from 91±56 to 38±21 frames, P < .001). By contrast, only 19% of patients with epicardial mechanical obstruction showed improvement in TIMI flow grade after verapamil, with minimal reduction in frames to opacification (from 107±42 to 101±69, P = .73). Conclusions: The no-reflow phenomenon-reduction in distal flow without apparent dissection or distal embolization - occurs in 2% of coronary interventions. It generally responds promptly to intracoronary verapamil administration, suggesting that distal microvascular spasm may be its etiology.

Original languageEnglish
Pages (from-to)2514-2518
Number of pages5
JournalCirculation
Volume89
Issue number6
StatePublished - Jun 1 1994

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Percutaneous Coronary Intervention
Verapamil
Incidence
No-Reflow Phenomenon
Dissection
Nitroglycerin
Therapeutics
Spasm
Embolism
Ischemia
Injections

Keywords

  • no-reflow phenomenon
  • percutaneous transluminal coronary angioplasty
  • verapamil

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine

Cite this

Piana, R. N., Paik, G. Y., Moscucci, M., Cohen, D. J., Gibson, C. M., Kugelmass, A. D., ... Baim, D. S. (1994). Incidence and treatment of 'no-reflow' after percutaneous coronary intervention. Circulation, 89(6), 2514-2518.

Incidence and treatment of 'no-reflow' after percutaneous coronary intervention. / Piana, Robert N.; Paik, George Y.; Moscucci, Mauro; Cohen, David J.; Gibson, C. Michael; Kugelmass, Aaron D.; Carrozza, Joseph P.; Kuntz, Richard E.; Baim, Donald S.

In: Circulation, Vol. 89, No. 6, 01.06.1994, p. 2514-2518.

Research output: Contribution to journalArticle

Piana, RN, Paik, GY, Moscucci, M, Cohen, DJ, Gibson, CM, Kugelmass, AD, Carrozza, JP, Kuntz, RE & Baim, DS 1994, 'Incidence and treatment of 'no-reflow' after percutaneous coronary intervention', Circulation, vol. 89, no. 6, pp. 2514-2518.
Piana RN, Paik GY, Moscucci M, Cohen DJ, Gibson CM, Kugelmass AD et al. Incidence and treatment of 'no-reflow' after percutaneous coronary intervention. Circulation. 1994 Jun 1;89(6):2514-2518.
Piana, Robert N. ; Paik, George Y. ; Moscucci, Mauro ; Cohen, David J. ; Gibson, C. Michael ; Kugelmass, Aaron D. ; Carrozza, Joseph P. ; Kuntz, Richard E. ; Baim, Donald S. / Incidence and treatment of 'no-reflow' after percutaneous coronary intervention. In: Circulation. 1994 ; Vol. 89, No. 6. pp. 2514-2518.
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abstract = "Background: Profound reduction in antegrade epicardial coronary flow with concomitant ischemia is seen occasionally during percutaneous coronary intervention despite the absence of evident vessel dissection, obstruction, or distal vessel embolic cutoff. In a prior small series of cases, this 'no- reflow' phenomenon appeared to be promptly reversed by the intracoronary administration of verapamil. Methods and Results: To further understand the prevalence of this syndrome and its responsiveness to the proposed therapy, we reviewed 1919 percutaneous interventions performed between January 1991 and April 1993. During the study period, 39 patients (2.0{\%}) met our criteria for no reflow, 37 of whom were treated with intracoronary nitroglycerin followed by intracoronary verapamil and 2 of whom received intracoronary nitroglycerin alone. An additional 16 patients (0.8{\%}) were given verapamil as part of the management of a flow-limiting dissection or distal embolus (mechanical obstruction). Intracoronary verapamil (50 to 900 μg, total dose) improved TIMI flow grade in 89{\%} of no-reflow patients and markedly reduced the number of cineframes between contrast injection and opacification of a selected distal landmark (from 91±56 to 38±21 frames, P < .001). By contrast, only 19{\%} of patients with epicardial mechanical obstruction showed improvement in TIMI flow grade after verapamil, with minimal reduction in frames to opacification (from 107±42 to 101±69, P = .73). Conclusions: The no-reflow phenomenon-reduction in distal flow without apparent dissection or distal embolization - occurs in 2{\%} of coronary interventions. It generally responds promptly to intracoronary verapamil administration, suggesting that distal microvascular spasm may be its etiology.",
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AU - Piana, Robert N.

AU - Paik, George Y.

AU - Moscucci, Mauro

AU - Cohen, David J.

AU - Gibson, C. Michael

AU - Kugelmass, Aaron D.

AU - Carrozza, Joseph P.

AU - Kuntz, Richard E.

AU - Baim, Donald S.

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N2 - Background: Profound reduction in antegrade epicardial coronary flow with concomitant ischemia is seen occasionally during percutaneous coronary intervention despite the absence of evident vessel dissection, obstruction, or distal vessel embolic cutoff. In a prior small series of cases, this 'no- reflow' phenomenon appeared to be promptly reversed by the intracoronary administration of verapamil. Methods and Results: To further understand the prevalence of this syndrome and its responsiveness to the proposed therapy, we reviewed 1919 percutaneous interventions performed between January 1991 and April 1993. During the study period, 39 patients (2.0%) met our criteria for no reflow, 37 of whom were treated with intracoronary nitroglycerin followed by intracoronary verapamil and 2 of whom received intracoronary nitroglycerin alone. An additional 16 patients (0.8%) were given verapamil as part of the management of a flow-limiting dissection or distal embolus (mechanical obstruction). Intracoronary verapamil (50 to 900 μg, total dose) improved TIMI flow grade in 89% of no-reflow patients and markedly reduced the number of cineframes between contrast injection and opacification of a selected distal landmark (from 91±56 to 38±21 frames, P < .001). By contrast, only 19% of patients with epicardial mechanical obstruction showed improvement in TIMI flow grade after verapamil, with minimal reduction in frames to opacification (from 107±42 to 101±69, P = .73). Conclusions: The no-reflow phenomenon-reduction in distal flow without apparent dissection or distal embolization - occurs in 2% of coronary interventions. It generally responds promptly to intracoronary verapamil administration, suggesting that distal microvascular spasm may be its etiology.

AB - Background: Profound reduction in antegrade epicardial coronary flow with concomitant ischemia is seen occasionally during percutaneous coronary intervention despite the absence of evident vessel dissection, obstruction, or distal vessel embolic cutoff. In a prior small series of cases, this 'no- reflow' phenomenon appeared to be promptly reversed by the intracoronary administration of verapamil. Methods and Results: To further understand the prevalence of this syndrome and its responsiveness to the proposed therapy, we reviewed 1919 percutaneous interventions performed between January 1991 and April 1993. During the study period, 39 patients (2.0%) met our criteria for no reflow, 37 of whom were treated with intracoronary nitroglycerin followed by intracoronary verapamil and 2 of whom received intracoronary nitroglycerin alone. An additional 16 patients (0.8%) were given verapamil as part of the management of a flow-limiting dissection or distal embolus (mechanical obstruction). Intracoronary verapamil (50 to 900 μg, total dose) improved TIMI flow grade in 89% of no-reflow patients and markedly reduced the number of cineframes between contrast injection and opacification of a selected distal landmark (from 91±56 to 38±21 frames, P < .001). By contrast, only 19% of patients with epicardial mechanical obstruction showed improvement in TIMI flow grade after verapamil, with minimal reduction in frames to opacification (from 107±42 to 101±69, P = .73). Conclusions: The no-reflow phenomenon-reduction in distal flow without apparent dissection or distal embolization - occurs in 2% of coronary interventions. It generally responds promptly to intracoronary verapamil administration, suggesting that distal microvascular spasm may be its etiology.

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