Abstract
A 72-year-old Chinese male with background cardiovascular risk factors of hypertension and diabetes mellitus underwent an elective coronary angiogram. He had a significant medical history of end stage renal failure on hemodialysis, paroxysmal atrial fibrillation on warfarin, anemia of chronic disease, and peptic ulcer disease. He was admitted for a recent creation of arteriovenous fistula which was complicated by a type 2 myocardial infarct with hypotension during dialysis. A transthoracic echocardiogram done showed that the left ventricular ejection fraction was still preserved at 55%. There were infero-septal wall motion abnormalities seen. A stress myocardial perfusion study was positive for ischemia over anteroseptal regions.
Case Summary
A 72-year-old Chinese male with background cardiovascular risk factors of hypertension and diabetes mellitus underwent an elective coronary angiogram. He had a significant medical history of end stage renal failure on hemodialysis, paroxysmal atrial fibrillation on warfarin, anemia of chronic disease, and peptic ulcer disease. He was admitted for a recent creation of arteriovenous fistula which was complicated by a type 2 myocardial infarct with hypotension during dialysis. A transthoracic echocardiogram done showed that the left ventricular ejection fraction was still preserved at 55%. There were infero-septal wall motion abnormalities seen. A stress myocardial perfusion study was positive for ischemia over anteroseptal regions.
The baseline coronary angiogram showed severe discrete calcified lesions in the proximal-mid left anterior descending artery (LAD; Fig. 21.1a, b; Videos 21.1 and 21.2). Femoral vascular access was used. A 6F JL 4 guide was used. The LAD was crossed with an Abbott Vascular Hi-Torque BMW Universal wire. Lesion preparation with a semi-compliant 2.0 mm balloon was suboptimal as the balloon “melon seeded” during initial lesion preparation. Further lesion preparation using the 2.5 mm AngioSculpt balloon was also not successful with bursting of the balloon at high pressures (Video 21.3). A decision was made to perform rotational atherectomy 1.5 mm burr on a Rotawire extra-support wire at 150,000 rpm (Video 21.4). No flow was noted after the rotational atherectomy (Video 21.5). Further predilation was performed with a noncompliant balloon 2.5 × 15 mm at 18 atm. After predilation, there was partial restoration of TIMI 1 flow (Video 21.6). 2 X BioFreedom DES (3. × 14 mm and 2.75 × 36 mm) were deployed from proximal to mid-LAD (Fig. 21.2a, b). An intracoronary cocktails of adenosine, nitroglycerin, and verapamil was given with improvement TIMI flow grade (Video 21.7). Post-dilation using the noncompliant Neich NC Sapphire II 3.0 × 15 was performed at 20 atm. Post procedure, good angiographic result was achieved with TIMI 3 flow seen in the LAD (Videos 21.8 and 21.9, Fig. 21.3a–c).
Discussion and Learning Points
No reflow after rotational atherectomy refers to the angiographic appearance of no blood flow in the treated artery even though the treated segment is patent. Sometimes there is blood flow but is reduced by one TIMI study flow grade which is known as slow flow.
No reflow is believed to occur due to a combination of factors including distal embolism of vessel debris after debulking or vasospasm in the microvasculature. It can also be caused by a flow-limiting dissection.
A series of measures may reduce the occurrence of no reflow or slow flow. These include:
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Slow, controlled advancement of the burr, focusing on “sandpapering” the lesion.
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Adoption of a progressive increase in burr size approach in long calcified lesions, preferably in 0.25–0.5 mm increments.
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Ensuring repeated saline flushes to maintain optimal blood flow.
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Using guide catheters with side holes.
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Using an intra-aortic balloon pump to improve diastolic flow in the coronaries.
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Intracoronary infusion of adenosine, nitroprusside, verapamil, and glyceryl trinitrate (GTN) can improve slow flow or no reflow after a short period of time, typically within seconds to minutes. Oftentimes, it is useful to pretreat the vessel with these drugs before rotational atherectomy:
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GTN 100–200 mcg. Multiple doses may be given as long as blood pressure tolerates.
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Verapamil: 100–200 mcg.
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Adenosine: 100–200 mcg. Multiple doses may be given as the drug is very short acting. Do note the risk of heart block and may provoke atrial fibrillation.
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Nitroprusside: 10–20 mcg.
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Intracoronary delivery of vasodilators may be improved by using a microcatheter (either end-hole or with side-port, such as an aspiration catheter) or by using an over-the-wire balloon inflated to ensure distal drug delivery.
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The baseline coronary angiogram showed tight discrete calcified lesions in the proximal-mid left anterior descending artery (MPG 595 kb)
The baseline coronary angiogram showed tight discrete calcified lesions in the proximal-mid left anterior descending artery (MPG 955 kb)
Lesion preparation using the AngioSculpt scoring balloon was unsuccessful with rupture of the balloon (MPG 1557 kb)
Rotational atherectomy of the vessel with a 1.5 mm burr at 150,000 RPM (MPG 1558 kb)
No reflow noted after the rotational atherectomy (MPG 700 kb)
Improved flow after balloon angioplasty (MPG 1195 kb)
Further improvement of coronary flow after intracoronary adenosine, verapamil, and glyceryl trinitrate (MPG 704 kb)
Final angiogram showing an excellent angiographic result (MPG 1331 kb)
Final angiogram showing an excellent angiographic result (MPG 944 kb)
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Fam, J.M., Yeo, K.K. (2018). Complication: No Reflow. In: Low, R., Yeo, K. (eds) Clinical Cases in Coronary Rotational Atherectomy. Clinical Cases in Interventional Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-319-60490-9_21
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DOI: https://doi.org/10.1007/978-3-319-60490-9_21
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