Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 61-year old man visited our emergency department for sudden onset chest pain. He did not have hypertension or diabetes. He was not a smoker. He did not diagnose with coronary artery disease before.
Relevant test results prior to catheterization
He was diagnosed with acute ST-segment elevation myocardial infarction (STEMI).
Relevant catheterization findings
The primary percutaneous coronary intervention (PCI) was performed immediately. The coronary angiography showed total occlusion of proximal left anterior descending (LAD) coronary artery. There is no stenosis of the right coronary artery.
GAIA first (ASAHI) guide wire passed softly through the true lumen. Balloon angioplasty done with 4.0 x 15 mm balloon. The coronary flow recovered as TIMI grade II, and there is a large thrombus in the mid-LAD. After that, balloon angioplasty repeatedly done for thrombus. Immediately after balloon angioplasty, the angiography showed no-reflow phenomenon. Glycoprotein IIb/III ainhibitor (Abciximab 15 mg, 0.25 mg/kg) was infused intracoronary (IC).However, the no-reflow phenomenon continued. IC Nicorandil (1.96 mg) and ICverapamil (200 mcg) were infused. The no-flow phenomenon continued.
Intravascular ultrasound (IVUS) performed. However, the IVUS catheter reached just before total occlusion lesion becauseof the tortuous mid-coronary artery. The IVUS showed no significant stenosis orthrombus formation just before occlusion. The procedure stopped unless thecoronary no-reflow remained. The vital sign was stable. The chest pain wasrelieved after PCI unless no-reflow.
The prediction of the no-reflow phenomenon was limited. Acute coronary syndrome, visible thrombus in the coronary artery, and prolonged reperfusion was the predictor of the no-reflow phenomenon. Glycoprotein IIb/IIIa inhibitor, verapamil, nicorandil, or intra-aortic balloon counter pulsation (IABP) was helpful to restore no-reflow.