Abrupt closure during coronary intervention: Difference between revisions

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{{PCI}}
{{PCI}}
'''Editor(s)-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], Alexandra Almonacid M.D. [mailto:aalmonacid@partners.org], Jeffrey J. Popma M.D. [mailto:jpopma@partners.org]; {{AE}} {{HP}}, {{Sapan}}
'''Editor(s)-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] {{AE}} {{HP}}, {{Sapan}}


==Overview==
==Overview==
Abrupt closure during [[interventional cardiology|coronary intervention]] is defined as an abrupt cessation of [[coronary blood flow|coronary flow]] to [[TIMI flow grade 0|TIMI 0]] or [[TIMI flow grade 1|1]].
Abrupt closure during [[interventional cardiology|coronary intervention]] is defined as an abrupt cessation of [[coronary blood flow|coronary flow]] to [[TIMI flow grade 0|TIMI grade 0]] or [[TIMI flow grade 1|1]] flow before or at ≤5 mm distal to the lesion in an artery in which [[PTCA]] was attempted where there had previously been [[TIMI flow grade 2|TIMI grade 2]] or [[TIMI flow grade 3|3]] flow prior to the procedure. It occurs primarily due to acute [[coronary dissection]], [[thrombosis]], or, most often, a combination of both during coronary intervention.
 
==Definition==
Abrupt closure during [[interventional cardiology|coronary intervention]] is defined as an abrupt cessation of [[coronary blood flow|coronary flow]] to [[TIMI flow grade 0|TIMI grade 0]] or [[TIMI flow grade 1|1]] flow before or at ≤5 mm distal to the lesion in an artery in which [[PTCA]] was attempted where there had previously been [[TIMI flow grade 2|TIMI grade 2]] or [[TIMI flow grade 3|3]] flow prior to the procedure. If [[TIMI flow grade 1]] was present prior to dilation, then the development of [[TIMI flow grade 0]] will constitute abrupt closure. In cases in which the artery being dilated had [[TIMI flow grade 0]] prior to the procedure, if [[TIMI flow grade 2]] or [[TIMI flow grade 3|3]] is achieved during the procedure, and if the procedure is completed with [[TIMI flow grade 0]], then this will also constitute abrupt closure. The table below outlines the possible scenarios that would be classified as abrupt closure:
 
{| style="width:75%; height:200px" border="1"
|-
! style="background:#efefef;" | Pre-[[PTCA]] Flow || style="background:#efefef;" | Post-[[PTCA]] Flow
|-
| [[TIMI flow grade 0]] with vessel patency established ([[TIMI flow grade 2]] or [[TIMI flow grade 3|3]]) during the procedure || [[TIMI flow grade 0]]
|-
| [[TIMI flow grade 1]] || [[TIMI flow grade 0]]
|-
| [[TIMI flow grade 2]] || [[TIMI flow grade 0]] or [[TIMI flow grade 1|1]]
|-
| [[TIMI flow grade 3]] || [[TIMI flow grade 0]] or [[TIMI flow grade 1|1]]
|}
 
==Classification==
Abrupt closure can be classified as sustained or transient:
*Sustained abrupt closure: Abrupt closure that has been present when the patient left the cardiac catheterization laboratory.
*Transient abrupt closure: Abrupt closure that has been treated with restoration of [[coronary blood flow]] to [[TIMI flow grade 2]] or [[TIMI flow grade 3|3]] before the patient left the cardiac catheterization laboratory.
 
==Causes==
==Causes==
Abrupt closure may be due to [[coronary dissection]], [[embolization]], or [[thrombus]] formation within the [[vessel]].
Abrupt closure occurs primarily as a result of acute [[coronary dissection]], [[thrombosis]], intracoronary spasm, [[embolization]], intra-procedural stent thrombosis or, most often, a combination of all the above during coronary intervention.
==Epidemiology and Demographics==
==Epidemiology and Demographics==
It occurs during 3-5% of balloon angioplasty procedures. Its [[incidence]] has been markedly reduced with the availability of [[coronary stent]]s.
It occurs during 3-5% of balloon angioplasty procedures. Its [[incidence]] has been markedly reduced with the availability of [[coronary stent]]s.
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*[[Diabetes]]
*[[Diabetes]]
==Treatment==
==Treatment==
===Stent Use in Abrupt Closure===
 
*Gianturco-Roubin [[stent]] improves [[lumen]] size and reduced MACE
*Intracoronary imaging as necessary to evaluate the cause
*PS [[stent]] improves outcome: [[mortality]] 1.3%, [[MI]] 4%, 1% [[CABG]]
*Intracoronary stent placement to treat dissection
*[[ACS]] Multi-Link: [[mortality]] 1.4%, MI 2.9%
*Intracoronary vasodilators to treat epicardial vessel and microvascular spasm
*Mostly associated with [[subacute]] [[Stent Thrombosis|stent thrombosis]]
*Imaging, additional dilation, anticoagulation and antiplatelets to treat intraprocedural stent thrombosis
*Rx: maintain flow, complete coverage.
 
==Abrupt Closure Examples==
==Abrupt Closure Examples==
===[[Abrupt closure case 1|Case 1]]===
===[[Abrupt closure case 1|Case 1]]===
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===[[Abrupt closure case 26|Case 26]]===
===[[Abrupt closure case 26|Case 26]]===
===[[Abrupt closure case 27|Case 27]]===
===[[Abrupt closure case 28|Case 28]]===
===[[Abrupt closure case 29|Case 29]]===


==References==
==References==
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[[CME Category::Cardiology]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Angiopedia]]
[[Category:Angiopedia]]
[[Category:Up-To-Date]]
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[[Category:Up-To-Date cardiology]]
[[Category:Up-To-Date cardiology]]
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Latest revision as of 13:00, 17 June 2020

Percutaneous coronary intervention Microchapters

Home

Patient Information

Overview

Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

Vascular Closure Devices

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

Post-PCI Management

Risk Reduction After PCI

Post-PCI follow up

Hybrid coronary revascularization

PCI approaches

PCI Complications

Factors Associated with Complications
Vessel Perforation
Dissection
Distal Embolization
No-reflow
Coronary Vasospasm
Abrupt Closure
Access Site Complications
Peri-procedure Bleeding
Restenosis
Renal Failure
Thrombocytopenia
Late Acquired Stent Malapposition
Loss of Side Branch
Multiple Complications

PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
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PCI in Specific Lesion Types

Classification of the Lesion
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The Angulated or Tortuous Lesion
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The Long Lesion
The Bridge Lesion
Vasospasm
The Chronic Total Occlusion
The Left Internal Mammary Artery
Multivessel Disease
Distal Anastomotic Lesions
Left Main Intervention
The Thrombotic Lesion

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Risk calculators and risk factors for Abrupt closure during coronary intervention

Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Hardik Patel, M.D., Sapan Patel M.B.B.S

Overview

Abrupt closure during coronary intervention is defined as an abrupt cessation of coronary flow to TIMI grade 0 or 1 flow before or at ≤5 mm distal to the lesion in an artery in which PTCA was attempted where there had previously been TIMI grade 2 or 3 flow prior to the procedure. It occurs primarily due to acute coronary dissection, thrombosis, or, most often, a combination of both during coronary intervention.

Definition

Abrupt closure during coronary intervention is defined as an abrupt cessation of coronary flow to TIMI grade 0 or 1 flow before or at ≤5 mm distal to the lesion in an artery in which PTCA was attempted where there had previously been TIMI grade 2 or 3 flow prior to the procedure. If TIMI flow grade 1 was present prior to dilation, then the development of TIMI flow grade 0 will constitute abrupt closure. In cases in which the artery being dilated had TIMI flow grade 0 prior to the procedure, if TIMI flow grade 2 or 3 is achieved during the procedure, and if the procedure is completed with TIMI flow grade 0, then this will also constitute abrupt closure. The table below outlines the possible scenarios that would be classified as abrupt closure:

Pre-PTCA Flow Post-PTCA Flow
TIMI flow grade 0 with vessel patency established (TIMI flow grade 2 or 3) during the procedure TIMI flow grade 0
TIMI flow grade 1 TIMI flow grade 0
TIMI flow grade 2 TIMI flow grade 0 or 1
TIMI flow grade 3 TIMI flow grade 0 or 1

Classification

Abrupt closure can be classified as sustained or transient:

  • Sustained abrupt closure: Abrupt closure that has been present when the patient left the cardiac catheterization laboratory.
  • Transient abrupt closure: Abrupt closure that has been treated with restoration of coronary blood flow to TIMI flow grade 2 or 3 before the patient left the cardiac catheterization laboratory.

Causes

Abrupt closure occurs primarily as a result of acute coronary dissection, thrombosis, intracoronary spasm, embolization, intra-procedural stent thrombosis or, most often, a combination of all the above during coronary intervention.

Epidemiology and Demographics

It occurs during 3-5% of balloon angioplasty procedures. Its incidence has been markedly reduced with the availability of coronary stents.

Risk Factors[1]

Natural History, Complications and Prognosis

Factors predicting mortality after abrupt closure are as follows:

Treatment

  • Intracoronary imaging as necessary to evaluate the cause
  • Intracoronary stent placement to treat dissection
  • Intracoronary vasodilators to treat epicardial vessel and microvascular spasm
  • Imaging, additional dilation, anticoagulation and antiplatelets to treat intraprocedural stent thrombosis

Abrupt Closure Examples

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9

Case 10

Case 11

Case 12

Case 13

Case 14

Case 15

Case 16

Case 17

Case 18

Case 19

Case 20

Case 21

Case 22

Case 23

Case 24

Case 25

Case 26

Case 27

Case 28

Case 29

References

  1. Suh WW, Grill DE, Rihal CS, Bell MR, Holmes DR, Garratt KN (2002). "Unrestricted availability of intracoronary stents is associated with decreased abrupt vascular closure rates and improved early clinical outcomes". Catheter Cardiovasc Interv. 55 (3): 294–302. PMID 11870931.

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