Features and outcome of no-reflow after percutaneous coronary intervention

No-reflow is an uncommon complication that may occur after revascularization of patients with acute myocardial infarction, after interventions in saphenous vein bypass grafts, and after the use of some new interventional devices. However, the clinical impact of no-reflow after coronary intervention is unknown. Accordingly, this study examined the incidence, clinical presentation, angiographic characteristics, and outcome of no-reflow after percutaneous coronary intervention. No-reflow was defined as an acute reduction in antegrade flow (≤1, as defined by the Thrombolysis in Myocardial Infarction [TIMI] trial) not attributable to abrupt closure, high-grade stenosis, or spasm of the original target lesion. Among 10,676 coronary interventions performed between October 1988 and June 1993, no-reflow occurred in 66 patients (0.6%). These patients were compared with a subgroup of 500 consecutive patients who did not exhibit no-reflow. The incidence of no-reflow was 30 of 9,431 (0.3%) for percutaneous transluminal coronary angioplasty, 1 of 317 (0.3%) for excimer laser, 8 of 104 (7.7%) for Rotablator (Heart Technologies, Bellevue, Washington), 21 of 469 (4.5%) for extraction atherectomy, and 6 of 355 (1.7%) for directional atherectomy. Compared with those without no-reflow, patients with no-reflow experienced a 10-fold higher incidence of in-hospital death (15%) and acute myocardial infarction (31%). Correlates of in-hospital mortality included acute myocardial infarction on presentation (p = 0.006) and final flow < 3 (as defined by the TIMI trial) at completion of the procedure (p = 0.03). Successful resolution of no-reflow was observed in only 19 of 66 patients (29%), and ranged from 10% with urokinase alone to 67% with intracoronary verapamil. By device, resolution of no-reflow was 63% after the Rotablator, 37% after angioplasty, 33% after directional atherectomy, 5% after extraction atherectomy, and 0% after excimer laser. In conclusion, no-reflow occurs infrequently but is clinically important because of the high incidence of subsequent death and myocardial infarction. The incidence of no-reflow is higher in the setting of acute myocardial infarction and after new atherectomy devices. Failure to normalize flow is associated with a poor outcome.