Adenosine use during aortocoronary vein graft interventions reverses but does not prevent the slow-no reflow phenomenon

Abstract

Slow or no reflow (SNR) complicates 10-15% of cases of percutaneous intervention (PI) in saphenous vein bypass graft (SVG). To date there have been limited options for the prevention and treatment of this common and potentially serious complication. We evaluated the procedural outcome of 143 consecutive SVG interventions. We compared patients who received pre-intervention intra-graft adenosine boluses with those who did not. In addition we examined the efficacy of adenosine boluses to reverse slow-no reflow events. Angiograms were reviewed and flow graded (TIMI grade) by film readers blinded to the use of any intraprocedural drug or clinical history. Seventy patients received intragraft adenosine boluses before percutaneous intervention (APPI), 73 received no preintervention adenosine (NoAPPI). There were no significant angiographic differences between the two groups at baseline. A total of 20 patients experienced SNR. The incidence of SNR was similar in the two groups (APPI = 14.2% vs. NoAPPI = 13.6%, P = 0.9). SNR was treated with repeated, rapid boluses (24 microg each) of intra-graft adenosine. Reversal of SNR was observed in 10 of 11 patients (91%) who received high doses of adenosine (>/=5 boluses, mean 7.7 +/- 2.6) and in 3 of 9 (33%) of those who received low doses (<5 boluses, mean 1.5 +/- 1.2). Final TIMI flow was significantly better in the high dose than in the low dose group (final TIMI 2.7 +/- 0.6 vs. 2 +/- 0.8, P = 0.04). No significant untoward complications were observed during adenosine infusion. These findings suggest that SNR after PI in SVG is not prevented by pre-intervention adenosine, but it can be safely and effectively reversed by delivery of multiple, rapid and repeated boluses of 24 microg of intra-graft adenosine.

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

“…8,230 -232 Several models have been developed and refined over the past 2 decades to predict mortality with PCI. 230,[233][234][235][236] At present, perhaps the best accepted system is from the ACC National Cardiovascular Data Registry (NCDR) CathPCI Risk Score system, which uses clinical variables and PCI setting to predict inpatient mortality (Appendix 4A). 236 In general, these models perform very well (C statistic: approximately 0.90), although predictive capability decreases in high-risk patients.…”

“…236 Factors associated with an increased risk of PCI-related death include advanced age, comorbidities (eg, diabetes, CKD, congestive heart failure), multivessel CAD, high-risk lesions, and the setting of PCI (eg, STEMI, urgent or emergency procedure, cardiogenic shock). 56,230 -232,236 Causes of procedural and periprocedural MI include acute artery closure, embolization and no-reflow, side branch occlusion, and acute stent thrombosis.…”

“…These include adenosine, calcium channel blockers, and nitroprusside. 676,678,679,681,684,686,689,691 There are fewer data to support the use of epinephrine. 692 No-reflow after rotational atherectomy was less common with nicorandil compared with verapamil infusions in 3 studies, [693][694][695] and an infusion of nicorandil/adenosine during rotational atherectomy prevented no-reflow in 98% of patients.…”

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

“…Administration of an intracoronary vasodilator (adenosine, calcium channel blocker, or nitroprusside) is reasonable to treat PCI-related no-reflow that occurs during primary or elective PCI (674)(675)(676)(677)(678)(679)(680)(681)(682)(683)(684)(685)(686)(687)(688)(689).…”

Percutaneous Saphenous Vein Graft Intervention—A Review

“…Multiple, rapid intragraft boluses of adenosine have been demonstrated to be safe and effective in reversing no-reflow in observational studies. 20,21 Platelet aggregation was naturally targeted as a possible cause of no-reflow phenomenon, however, adjunctive use of platelet glycoprotein IIb/IIIa inhibitors do not appear to reduce myonecrosis or improve survival in SVG intervention. [22][23][24] Distal Embolic Protection Devices DISTAL OCCLUSION.…”