Treating acute "no-reflow" with intracoronary adenosine in 4 patients during percutaneous coronary intervention

Abstract

Angiographic evidence of impaired tissue perfusion, known as the "no-reflow" phenomenon, is a serious complication of percutaneous coronary intervention-one that is associated with increased mortality rates. Adenosine is an endogenous nucleoside that attenuates many of the mechanisms that are responsible for no-reflow. Herein, we report the cases of 4 patients who developed the no-reflow phenomenon after elective percutaneous coronary intervention to their native coronary arteries and saphenous vein grafts. In all 4 patients, and without adverse effects, small bolus doses of adenosine through the guiding catheter improved epicardial perfusion--measured by either Thrombolysis In Myocardial Infarction (TIMI) flow grade or corrected TIMI frame count-and tissue-level perfusion, graded according to myocardial blush. In view of adenosine's extremely short half-life in blood, the continuous administration of adenosine into the distal vascular bed throughout percutaneous coronary intervention may further improve outcomes by reversing or preventing the no-reflow phenomenon.

Keywords: Adenosine/administration & dosage/physiology/therapeutic use; angioplasty, transluminal, percutaneous coronary/adverse effects/methods; atherosclerosis/complications/therapy; cardiotonic agents/administration & dosage/therapeutic use; coronary vessels/drug effects; creatine kinase/blood; dose-response relationship, drug; graft occlusion, vascular/therapy; myocardial reperfusion/methods; treatment outcome; vasodilator agents/administration & dosage/therapeutic use.

Fig. 1 A) Pre-interventional angiogram shows a severe, smooth focal stenosis at the origin of the saphenous vein graft (arrow) to the 3rd marginal branch, which was diffusely diseased. The Thrombolysis In Myocardial Infarction (TIMI) flow was grade 3, and the corrected TIMI frame count (CTFC) was 40. B) After primary stenting, no-reflow (TIMI grade, 0) occurred (arrow), with no residual stenosis at the stent site. C) After the administration of a total of 100 μg of adenosine through the guiding catheter, TIMI flow improved to grade 2, and the CTFC to 50. The arrow indicates good opacification of the marginal vessel.

Fig. 2 A) Initial angiogram shows a 95% stenosis of the proximal LAD (arrow) with involvement of the 1st diagonal branch. The Thrombolysis In Myocardial Infarction (TIMI) flow grade was 3, and the corrected TIMI frame count (CTFC) was 24. B) After predilation, no-reflow was evident, with the TIMI flow decreasing to 0 (arrow). C) After the administration of a total of 120 μg of intracoronary adenosine, and then stent placement (white arrow), the TIMI flow was restored to grade 3 and the CTFC to 20. The lesion in the diagonal branch remained unchanged (black arrow).

Fig. 3 A) Baseline angiogram shows severe stenosis of the proximal RCA with possible thrombus (arrow); the Thrombolysis In Myocardial Infarction (TIMI) flow grade was 2, and the corrected TIMI frame count (CTFC) was 44. B) After placement of the guidewire, the TIMI flow decreased to 1 and the CTFC increased to 80 (upper arrow, lesion; lower arrow, no-reflow). C) After two 18-μg boli of adenosine, the TIMI flow improved to grade 2 and the CTFC improved to 52. The arrow indicates opacification of the distal vessel. D) After balloon dilation (upper arrow), the TIMI flow further improved to grade 3 and the CTFC to 22 (lower arrow shows flow in posterolateral branch). E) After stent placement (upper arrow), no-reflow is evident (lower arrow), with TIMI grade-1 flow and a CTFC of 80. F) Another 36-μg infusion of adenosine restored the TIMI flow to 3 and the CTFC to 38; the posterolateral branch was well opacified (arrow).

Fig. 4 A) Pre-interventional angiogram reveals an eccentric plaque in the proximal left anterior descending coronary artery (LAD) (upper arrow) and a severe focal stenosis in the mid-LAD after the 1st diagonal branch (lower arrow). The Thrombolysis In Myocardial Infarction (TIMI) flow grade was 3, and the corrected TIMI frame count (CTFC) was 36. B) After angioplasty of the mid-LAD, luminal narrowing was reduced to 30% (arrow), with TIMI grade-3 flow and a CTFC of 26. C) Epicardial flow remained normal after the deployment of an undersized stent (arrow) to the mid-LAD lesion. D) After intravascular ultrasonography and stenting of the proximal lesion (upper arrow), dilation of the mid-LAD stent with a 3.5-mm balloon resulted in no-reflow with a TIMI flow grade of 0 (lower arrow). E) After the administration of a total of 150 μg of intracoronary adenosine, the TIMI flow was restored to normal, and the CTFC was 34 (arrow).