![]() Case Presentation: A 50-year-old gentleman with a past medical history of insulin dependent diabetes and essential hypertension who presented for typical chest pain. In this case report we discuss a patient scenario in which coronary no reflow occurred after elective PCI and was managed in the catheterization laboratory. Therapy is dependent upon the underlying etiology. The mechanism is likely multifactorial and consists of causes including distal embolization of thrombus fragments during PCI, microvascular dysfunction, coronary dissection, and vasospasm. Coronary no reflow is defined when TIMI flow grades are 0. After percutaneous coronary intervention (PCI), coronary filling is assessed using the Thrombolysis in Myocardial Infarction (TIMI) grading system. Although more research is needed for appropriate prevention of no reflow, early studies indicate that factors such as reducing time to intervention and administration of pre-procedural medications such as aspirin, beta-blocker, and heparin may improve microvascular integrity and reduce risk of subsequent no reflow.Ībstract = "Background: The phenomenon of coronary no reflow is defined as inadequate myocardial perfusion through without angiographic evidence of epicardial obstruction. Our patient responded well to vasodilator therapy with eventual improved coronary flow. Pharmacotherapy for the treatment of no reflow is targeted towards local vasodilator or antiplatelet therapy. ![]() During our patient case, after no reflow was appreciated IVUS was incorporated to help discern the etiology. IVUS has become an invaluable tool in helping to define underlying etiology of no reflow and ruling out coronary dissection. Our patient did display risk factors including smoking and diabetes, placing him at increased risk. Risk factors of no reflow include age, smoking, diabetes mellitus, and depressed left ventricular ejection fraction. Multiple doses of vasodilator medications, including nitroprusside and nicardipine, were administered with ultimate improvement of blood flow to the coronary artery with TIMI III flow.ĭiscussion: Coronary no reflow phenomenon is recognized in less than 2% of elective PCI cases. Intravascular Ultrasound (IVUS) was utilized which did not reveal any evidence of coronary artery dissection and good stent apposition was appreciated. Subsequent angiography revealed continued no reflow. A second drug-eluting stent was deployed proximal to the stent in an overlapping fashion. Subsequently, a drug eluting stent was deployed to the mid and distal right coronary artery which did not improve blood flow to the artery. Upon repeat coronary angiogram poor blood flow distal to the lesion was appreciated and acute dissection was suspected. The patient subsequently had ST segment elevations in the inferior leads and concurrent chest pain. The patient underwent coronary angiogram which revealed 80% disease of the mid right coronary artery in which PCI was performed. Ultimately a decision was made to pursue additional ischemic evaluation with coronary angiogram. Upon presentation to our facility, the patient had lab work that was significant for a troponin level within normal limits and an electrocardiogram that did not reveal any evidence of acute ischemia. Prior to presentation, the patient had recently had an echocardiogram that revealed an ejection fraction of 50-55%. In this case report we discuss a patient scenario in which coronary no reflow occurred after elective PCI and was managed in the catheterization laboratory.Ĭase Presentation: A 50-year-old gentleman with a past medical history of insulin dependent diabetes and essential hypertension who presented for typical chest pain. Background: The phenomenon of coronary no reflow is defined as inadequate myocardial perfusion through without angiographic evidence of epicardial obstruction.
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