Tejas Patel, MD | Sanjay Shah, MD | Samir B. Pancholy, MD

Chapter 5: Coronary No-Reflow and Air Embolism

Coronary “no-reflow” is a sign of insufficient myocardial perfusion in the absence of flow-limiting epicardial vessel obstruction, dissection, spasm, or distal macro-embolus.1-6 The most efficacious approach to no-reflow is to prevent its occurrence. In this regard, case selection is critical to avoid the possibility of no-reflow. For example, the interventionalist might avoid tackling a severely degenerated saphenous vein graft (SVG) with multiple filling defects and instead choose revascularizing the native vessel when possible.5,6 When considering primary percutaneous coronary intervention (PCI) in acute myocardial infarction (MI), minimizing the door-to-balloon time may reduce the incidence of no-reflow.5-9 The interventionalist can also reduce the incidence of no-reflow by minimizing barotrauma and distal embolization by limiting the number, diameter, and pressure of balloon inflations when stenting high-risk lesions.7-9 Prevention of no-reflow while performing rotational atherectomy can be done by avoiding thrombus-containing lesions, reducing the burr-to-artery ratio to 0.6 or less, and lowering the rotational speed to approximately 140,000 rpm in conjunction with adjunctive standard pharmacologic measures.5,6

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