The saline technique: a new frontier in coronary no-reflow management

Acute coronary syndromes (ACS) are frequently the first manifestation of cardiovascular disease and require timely intervention. Primary percutaneous coronary intervention (pPCI) significantly reduces mortality and major adverse cardiovascular events in patients with ST-elevation myocardial infarction (STEMI). However, despite successful epicardial recanalization, pPCI can be complicated by inadequate myocardial reperfusion, a phenomenon known as coronary no-reflow (NR) or microvascular obstruction (MVO), which is associated with adverse outcomes. The aim is to describe a novel interventional approach - the saline technique - for the treatment of MVO following stent implantation during pPCI. The saline technique consists of a rapid, manual intracoronary injection of 10 mL of saline over 2-4 seconds using a 6-Fr thrombus aspiration catheter positioned distally to the stented segment. The aim is to rapidly increase distal coronary pressure and volume, promoting microvascular recruitment and displacement of micro-emboli and vasoconstrictive agents. A diagnostic step using distal angiography precedes treatment to confirm MVO. Preliminary data from a single-center matched cohort (N.=32) showed that the Saline Technique significantly improved TIMI flow grade and ST-segment resolution compared to standard care. No major complications were observed. Post-procedural Index of Microvascular Resistance (IMR) was reduced in most cases. The saline technique is a safe, cost-effective, and rapidly deployable option for managing coronary NR/MVO. While promising, these findings are hypothesis-generating and require confirmation in larger, randomized trials.