Heart and Vessels

, Volume 26, Issue 4, pp 363–369

Prediction of the no-reflow phenomenon during percutaneous coronary intervention using coronary computed tomography angiography

  • Hiroto Harigaya
  • Sadako Motoyama
  • Masayoshi Sarai
  • Kaori Inoue
  • Tomonori Hara
  • Masanori Okumura
  • Hiroyuki Naruse
  • Junnichi Ishii
  • Hitoshi Hishida
  • Yukio Ozaki
Original Article


Coronary computed tomography angiography (CTA) can assess plaque characteristics and plaque size noninvasively. The purpose of this study was to investigate whether coronary CTA before percutaneous coronary intervention (PCI) can predict the no-reflow phenomenon during PCI. Seventy-eight patients [acute coronary syndrome (ACS) = 43, stable angina pectoris (SAP) = 35, male/female = 72/6, age: 65 ± 10 years] who underwent 16- or 64-slice CTA in the 4 weeks before PCI were enrolled. The low attenuation plaque size on CTA was compared between patients with (NR+) and without the no-reflow phenomenon (NR−). No-reflow phenomenon was observed in 11 patients, including 10 patients with ACS and 1 patient with SAP. Low attenuation plaque was detected in 9 (82%) NR(+) lesions and 35 (52%) NR(−) lesions. The length of low attenuation plaque was significantly longer in NR(+) than in NR(−) patients (9.0 ± 6.5 vs. 1.6 ± 2.7 mm, p < 0.0001). On step-wise regression analysis, ACS (p = 0.036, 95% CI = 0.009–0.258) and the presence of low attenuation plaque with a length >4.7 mm (p < 0.001, 95% CI = 0.447–0.778) were significant independent predictors of NR(−) no-reflow phenomenon. Low attenuation plaque with lesion length of >4.7 mm on coronary CTA and ACS were the significant predictors for the no-reflow phenomenon during PCI. Coronary CTA assessment before PCI would be useful to predict coronary events during PCI in advance.


Computed tomography angiography No-reflow phenomenon Percutaneous coronary intervention 


  1. 1.
    Weaver WD, Simes RJ, Betriu A, Grines CL, Zijlstra F, Garcia E, Grinfeld L, Gibbons RJ, Ribeiro EE, DeWood MA, Ribichini F (1997) Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA 278:2093–2098PubMedCrossRefGoogle Scholar
  2. 2.
    Ito H, Okamura A, Iwakura K, Masuyama T, Hori M, Takiuchi S, Negoro S, Nakatsuchi Y, Taniyama Y, Higashino Y, Fujii K, Minamino T (1996) Myocardial perfusion patterns related to thrombolysis in myocardial infarction perfusion grades after coronary angioplasty in patients with acute anterior wall myocardial infarction. Circulation 93:1993–1999PubMedGoogle Scholar
  3. 3.
    Keeley EC, Boura JA, Grines CL (2003) Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 361:13–20PubMedCrossRefGoogle Scholar
  4. 4.
    (1985) The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. TIMI Study Group. N Engl J Med 312:932–936Google Scholar
  5. 5.
    Reffelmann T, Kloner RA (2002) The “no-reflow” phenomenon: basic science and clinical correlates. Heart 87:162–168PubMedCrossRefGoogle Scholar
  6. 6.
    Simes RJ, Topol EJ, Holmes DR Jr, White HD, Rutsch WR, Vahanian A, Simoons ML, Morris D, Betriu A, Califf RM, Ross AM (1995) Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion. Importance of early and complete infarct artery reperfusion. GUSTO-I Investigators. Circulation 91:1923–1928PubMedGoogle Scholar
  7. 7.
    Nagao K, Hayashi N, Kanmatsuse K, Kikuchi S, Ohuba T, Takahashi H (2002) An early and complete reperfusion strategy for acute myocardial infarction using fibrinolysis and subsequent transluminal therapy—the FAST trial. Circ J 66:576–582PubMedCrossRefGoogle Scholar
  8. 8.
    Piana RN, Paik GY, Moscucci M, Cohen DJ, Gibson CM, Kugelmass AD, Carrozza JP Jr, Kuntz RE, Baim DS (1994) Incidence and treatment of ‘no-reflow’ after percutaneous coronary intervention. Circulation 89:2514–2518PubMedGoogle Scholar
  9. 9.
    Morishima I, Sone T, Mokuno S, Taga S, Shimauchi A, Oki Y, Kondo J, Tsuboi H, Sassa H (1995) Clinical significance of no-reflow phenomenon observed on angiography after successful treatment of acute myocardial infarction with percutaneous transluminal coronary angioplasty. Am Heart J 130:239–243PubMedCrossRefGoogle Scholar
  10. 10.
    Morishima I, Sone T, Okumura K, Tsuboi H, Kondo J, Mukawa H, Matsui H, Toki Y, Ito T, Hayakawa T (2000) Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction. J Am Coll Cardiol 36:1202–1209PubMedCrossRefGoogle Scholar
  11. 11.
    Cura FA, L’Allier PL, Kapadia SR, Houghtaling PL, Dipaola LM, Ellis SG, Topol EJ, Brener SJ (2001) Predictors and prognosis of suboptimal coronary blood flow after primary coronary angioplasty in patients with acute myocardial infarction. Am J Cardiol 88:124–128PubMedCrossRefGoogle Scholar
  12. 12.
    Ellis SG, Roubin GS, King SB 3rd, Douglas JS Jr, Weintraub WS, Thomas RG, Cox WR (1988) Angiographic and clinical predictors of acute closure after native vessel coronary angioplasty. Circulation 77:372–379PubMedCrossRefGoogle Scholar
  13. 13.
    Webb JG, Carere RG, Virmani R, Baim D, Teirstein PS, Whitlow P, McQueen C, Kolodgie FD, Buller E, Dodek A, Mancini GB, Oesterle S (1999) Retrieval and analysis of particulate debris after saphenous vein graft intervention. J Am Coll Cardiol 34:468–475PubMedCrossRefGoogle Scholar
  14. 14.
    Watson PS, Hadjipetrou P, Cox SV, Pyne CT, Gossman DE, Piemonte TC, Eisenhauer AC (1999) Angiographic and clinical outcomes following acute infarct angioplasty on saphenous vein grafts. Am J Cardiol 83:1018–1021PubMedCrossRefGoogle Scholar
  15. 15.
    Hamada S, Nakamura S, Sugiura T, Murakami T, Fujimoto T, Watanabe J, Baden M, Hatada K, Iwasaka T (1999) Early detection of the no-reflow phenomenon in reperfused acute myocardial infarction using technetium-99m tetrofosmin imaging. Eur J Nucl Med 26:208–214PubMedCrossRefGoogle Scholar
  16. 16.
    Iwakura K, Ito H, Kawano S, Shintani Y, Yamamoto K, Kato A, Ikushima M, Tanaka K, Kitakaze M, Hori M, Higashino Y, Fujii K (2001) Predictive factors for development of the no-reflow phenomenon in patients with reperfused anterior wall acute myocardial infarction. J Am Coll Cardiol 38:472–477PubMedCrossRefGoogle Scholar
  17. 17.
    Iwakura K, Ito H, Nishikawa N, Hiraoka K, Sugimoto K, Higashino Y, Masuyama T, Hori M, Fujii K, Minamino T (1999) Early temporal changes in coronary flow velocity patterns in patients with acute myocardial infarction demonstrating the “no-reflow” phenomenon. Am J Cardiol 84:415–419PubMedCrossRefGoogle Scholar
  18. 18.
    Sahin M, Basoglu T, Canbaz F, Elcik M, Kosus A (2002) The value of the TIMI frame count method in the diagnosis of coronary no-reflow: a comparison with myocardial perfusion SPECT in patients with acute myocardial infarction. Nucl Med Commun 23:1205–1210PubMedCrossRefGoogle Scholar
  19. 19.
    Henriques JP, Zijlstra F, Van‘t Hof AW, de Boer MJ, Dambrink JH, Gosselink M, Hoorntje JC, Suryapranata H (2003) Angiographic assessment of reperfusion in acute myocardial infarction by myocardial blush grade. Circulation 107:2115–2119PubMedCrossRefGoogle Scholar
  20. 20.
    Watanabe T, Nanto S, Uematsu M, Ohara T, Morozumi T, Kotani J, Nishio M, Awata M, Nagata S, Hori M (2003) Prediction of no-reflow phenomenon after successful percutaneous coronary intervention in patients with acute myocardial infarction: intravascular ultrasound findings. Circ J 67:667–671PubMedCrossRefGoogle Scholar
  21. 21.
    Katayama T, Kubo N, Takagi Y, Funayama H, Ikeda N, Ishida T, Hirahara T, Sugawara Y, Yasu T, Kawakami M, Saito M (2006) Relation of atherothrombosis burden and volume detected by intravascular ultrasound to angiographic no-reflow phenomenon during stent implantation in patients with acute myocardial infarction. Am J Cardiol 97:301–304PubMedCrossRefGoogle Scholar
  22. 22.
    Tanaka A, Kawarabayashi T, Nishibori Y, Sano T, Nishida Y, Fukuda D, Shimada K, Yoshikawa J (2002) No-reflow phenomenon and lesion morphology in patients with acute myocardial infarction. Circulation 105:2148–2152PubMedCrossRefGoogle Scholar
  23. 23.
    Komatsu S, Sato Y, Ichikawa M, Kunimasa T, Ito S, Takagi T, Lee T, Matsumoto N, Takayama T, Hirayama A, Mishima M, Saito S, Kodama K (2008) Anomalous coronary arteries in adults detected by multislice computed tomography: presentation of cases from multicenter registry and review of the literature. Heart Vessels 23:26–34PubMedCrossRefGoogle Scholar
  24. 24.
    Noda M, Takagi A, Kuwatsuru R, Mitsuhashi N, Kasanuki H (2008) Prognostic significance of multiple-detector computed tomography in conjunction with TIMI risk score for patients with non-ST elevation acute coronary syndrome. Heart Vessels 23:161–166PubMedCrossRefGoogle Scholar
  25. 25.
    Hamon M, Morello R, Riddell JW (2007) Coronary arteries: diagnostic performance of 16- versus 64-section spiral CT compared with invasive coronary angiography––meta-analysis. Radiology 245:720–731PubMedCrossRefGoogle Scholar
  26. 26.
    Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, Scherer M, Bellinger R, Martin A, Benton R, Delago A, Min JK (2008) Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 52:1724–1732PubMedCrossRefGoogle Scholar
  27. 27.
    Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox C, Brinker J, Lima JA (2008) Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 359:2324–2336PubMedCrossRefGoogle Scholar
  28. 28.
    Hoffmann U, Moselewski F, Nieman K, Jang IK, Ferencik M, Rahman AM, Cury RC, Abbara S, Joneidi-Jafari H, Achenbach S, Brady TJ (2006) Noninvasive assessment of plaque morphology and composition in culprit and stable lesions in acute coronary syndrome and stable lesions in stable angina by multidetector computed tomography. J Am Coll Cardiol 47:1655–1662PubMedCrossRefGoogle Scholar
  29. 29.
    Inoue F, Sato Y, Matsumoto N, Tani S, Uchiyama T (2004) Evaluation of plaque texture by means of multislice computed tomography in patients with acute coronary syndrome and stable angina. Circ J 68:840–844PubMedCrossRefGoogle Scholar
  30. 30.
    Leber AW, Knez A, Becker A, Becker C, von Ziegler F, Nikolaou K, Rist C, Reiser M, White C, Steinbeck G, Boekstegers P (2004) Accuracy of multidetector spiral computed tomography in identifying and differentiating the composition of coronary atherosclerotic plaques: a comparative study with intracoronary ultrasound. J Am Coll Cardiol 43:1241–1247PubMedCrossRefGoogle Scholar
  31. 31.
    Achenbach S, Ropers D, Hoffmann U, MacNeill B, Baum U, Pohle K, Brady TJ, Pomerantsev E, Ludwig J, Flachskampf FA, Wicky S, Jang IK, Daniel WG (2004) Assessment of coronary remodeling in stenotic and nonstenotic coronary atherosclerotic lesions by multidetector spiral computed tomography. J Am Coll Cardiol 43:842–847PubMedCrossRefGoogle Scholar
  32. 32.
    Motoyama S, Kondo T, Anno H, Sugiura A, Ito Y, Mori K, Ishii J, Sato T, Inoue K, Sarai M, Hishida H, Narula J (2007) Atherosclerotic plaque characterization by 0.5-mm-slice multislice computed tomographic imaging. Circ J 71:363–366PubMedCrossRefGoogle Scholar
  33. 33.
    Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O’Reilly MG, Winters WL, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC (2002) ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 40:1531–1540PubMedCrossRefGoogle Scholar
  34. 34.
    Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE 3rd, Steward DE, Theroux P, Gibbons RJ, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Smith SC Jr (2002) ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction––summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 40:1366–1374PubMedCrossRefGoogle Scholar
  35. 35.
    Motoyama S, Kondo T, Sarai M, Sugiura A, Harigaya H, Sato T, Inoue K, Okumura M, Ishii J, Anno H, Virmani R, Ozaki Y, Hishida H, Narula J (2007) Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes. J Am Coll Cardiol 50:319–326PubMedCrossRefGoogle Scholar
  36. 36.
    Motoyama S, Sarai M, Harigaya H, Anno H, Inoue K, Hara T, Naruse H, Ishii J, Hishida H, Wong ND, Virmani R, Kondo T, Ozaki Y, Narula J (2009) Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol 54:49–57PubMedCrossRefGoogle Scholar
  37. 37.
    Kloner RA, Alker KJ (1984) The effect of streptokinase on intramyocardial hemorrhage, infarct size, and the no-reflow phenomenon during coronary reperfusion. Circulation 70:513–521PubMedCrossRefGoogle Scholar
  38. 38.
    Kirma C, Izgi A, Dundar C, Tanalp AC, Oduncu V, Aung SM, Sonmez K, Mutlu B, Ozdemir N, Erentug V (2008) Clinical and procedural predictors of no-reflow phenomenon after primary percutaneous coronary interventions: experience at a single center. Circ J 72:716–721PubMedCrossRefGoogle Scholar
  39. 39.
    Skyschally A, Erbel R, Heusch G (2003) Coronary microembolization. Circ J 67:279–286PubMedCrossRefGoogle Scholar
  40. 40.
    Schroeder S, Kopp AF, Baumbach A, Meisner C, Kuettner A, Georg C, Ohnesorge B, Herdeg C, Claussen CD, Karsch KR (2001) Noninvasive detection and evaluation of atherosclerotic coronary plaques with multislice computed tomography. J Am Coll Cardiol 37:1430–1435PubMedCrossRefGoogle Scholar
  41. 41.
    Nakazawa G, Tanabe K, Onuma Y, Yachi S, Aoki J, Yamamoto H, Higashikuni Y, Yagishita A, Nakajima H, Hara K (2008) Efficacy of culprit plaque assessment by 64-slice multidetector computed tomography to predict transient no-reflow phenomenon during percutaneous coronary intervention. Am Heart J 155:1150–1157PubMedCrossRefGoogle Scholar
  42. 42.
    Cademartiri F, Mollet NR, Runza G, Bruining N, Hamers R, Somers P, Knaapen M, Verheye S, Midiri M, Krestin GP, de Feyter PJ (2005) Influence of intracoronary attenuation on coronary plaque measurements using multislice computed tomography: observations in an ex vivo model of coronary computed tomography angiography. Eur Radiol 15:1426–1431PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2010

Authors and Affiliations

  • Hiroto Harigaya
    • 1
  • Sadako Motoyama
    • 1
  • Masayoshi Sarai
    • 1
  • Kaori Inoue
    • 1
  • Tomonori Hara
    • 1
  • Masanori Okumura
    • 1
  • Hiroyuki Naruse
    • 1
  • Junnichi Ishii
    • 1
  • Hitoshi Hishida
    • 1
  • Yukio Ozaki
    • 1
  1. 1.Department of CardiologyFujita Health UniversityToyoakeJapan

Personalised recommendations