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No-Reflow Complicating Chronic Total Occlusion Coronary Revascularization
Gianni Dall'Ara1, Luca Testa, Carlo Tumscitz
1Cardiology Unit, Morgagni-Pierantoni Hospital, Cardiovascular Department ASL Romagna, via Forlanini 34, 47121 Forlì, Italy. dallara.gianni@gmail.com.
Insights
No-reflow is a rare complication of chronic total occlusion percutaneous coronary intervention (CTO-PCI), occurring in 0.43% of cases. Distal embolization is the likely cause, and intracoronary adenosine can effectively improve flow, though it carries a high risk of myocardial infarction.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is a complex procedure.
- No-reflow is a potential complication that can lead to adverse outcomes.
Purpose of the Study:
- To assess the incidence of no-reflow during CTO-PCI.
- To analyze causes and management strategies for no-reflow.
- To identify risks associated with no-reflow in CTO procedures.
Main Methods:
- A multicenter observational study reviewed CTO-PCIs performed between January 2018 and April 2019.
- No-reflow was defined as Thrombolysis in Myocardial Infarction (TIMI) flow ≤1.
- Clinical, anatomical, and procedural characteristics were analyzed.
Main Results:
- Two out of 461 CTO-PCIs (0.43%) were complicated by no-reflow.
- Distal embolization was the most plausible cause in both cases.
- Intracoronary adenosine improved flow, and both patients experienced type 4a myocardial infarction.
Conclusions:
- No-reflow is a rare but serious complication of CTO recanalization.
- It is associated with a high risk of periprocedural myocardial infarction.
- Existing collateral circulation offers incomplete protection against ischemia during CTO-PCI.
Objectives:
To assess the incidence of no-reflow in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI), analyze possible causes and differential diagnoses, and identify useful management approaches.
Methods:
In this multicenter observational study, all CTO-PCIs performed between January 2018 and April 2019 were reviewed to collect no-reflow complications, defined as Thrombolysis in Myocardial Infarction (TIMI) flow ≤1 in a patent epicardial artery. Patient clinical, anatomical, and procedural characteristics were analyzed.
Results:
Out of 461 PCIs, two (0.43%) were complicated by no-reflow. In 1 case, PCI was performed on a long segment of the right coronary artery, after use of a dissection-re-entry technique by knuckle wiring. In the second patient, no-reflow developed after proximal left anterior descending coronary artery stenting, with a short subintimal tracking. Intravascular ultrasound was used to exclude complications in the epicardial vessel in both cases. Distal embolization seems the most plausible cause, and intracoronary adenosine effectively improved flow. Both patients had a type 4a myocardial infarction, asymptomatic in the first case, and associated with chest pain, electrocardiographic changes, and new regional wall-motion abnormality at echocardiography in the second case.
Conclusions:
No-reflow in CTO recanalization is rare, but associated with a high risk of periprocedural myocardial infarction, with incomplete protection from ischemia offered by the pre-existing collateral network.
