CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/no-reflowIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • ImageTIMI 0 to 2 flow after stenting, atherectomy or thrombectomy with an open epicardial vessel: contrast crawls and hangs, with no flap and no cutoff 12.
  • MonitorST elevation, bradycardia, hypotension or ventricular arrhythmia as flow slows 2.
  • PatientChest pain returns after the vessel looked open.
  • ImageMost common in vein graft PCI, primary PCI with heavy thrombus and atherectomy 13.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Keep the wire across and stop advancing devices 2.
  2. Rule out a mechanical cause that needs a stent or aspiration instead: dissection, thrombus, spasm or a pseudolesion; image with IVUS or OCT if unclear 12.
  3. Tell the team, check the ACT and support the pressure and rhythm.
  4. Deliver vasodilators to the distal bed through a microcatheter, an aspiration catheter or the lumen of an over the wire balloon, not through the guide alone.
  5. Give nicardipine, adenosine or nitroprusside in repeated small doses and reassess flow and pressure after each 41.
  6. Aspirate if thrombus or debris may be the cause; laser if aspiration fails 2.
  7. Do not add stents for plaque embolization; more stents release more debris 2.
  8. Hemodynamic support if hypotension persists 25.
  9. Sources differ: intracoronary nitroglycerin relieves spasm but does not treat microvascular no reflow 1.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Nicardipine IC100 to 300 mcg; the preferred agent in Brilakis, with less hypotension and a shorter action 4.
  • Adenosine ICRight coronary 50 to 100 mcg; left 100 to 200 mcg; several thousand mcg can be given slowly for no reflow 4.Weight based dose in the Cath Med App
  • Nitroprusside IC100 to 300 mcg 4; Kern gives 100 to 200 mcg boluses (100 mcg/mL, 1 to 2 mL) 1.
  • Verapamil IC1 mg over 2 minutes 4.Product in the directory
  • Sources differ: Kern gives verapamil as 100 to 200 mcg boluses and notes that several grams of these agents in total may be needed; Brilakis gives 1 mg over 2 minutes 14.
  • Glycoprotein IIb/IIIa inhibitorWhen thrombus is the cause 1.Weight based dose in the Cath Med App

Who to call

The escalation ladder, first call first.

  1. Second operator: to run the microcatheter while you watch the pressure.
  2. Shock team: for hypotension that does not respond to drugs 2.
  3. Anesthesia: if the patient needs airway support.

The bailout step by step

Distal vasodilator delivery through a microcatheter

  1. Keep the coronary wire in place.
  2. Advance a microcatheter or an aspiration catheter over the wire to beyond the stented segment.
  3. Remove the wire from the microcatheter only if you can recross easily; otherwise use an over the wire balloon lumen or the aspiration catheter.
  4. Aspirate first, discard the aspirate, then flush.
  5. Inject one agent in small aliquots: nicardipine 100 to 300 mcg, or adenosine 100 to 200 mcg in the left system 4.
  6. Reassess flow, ST segments and pressure after each dose; repeat as the pressure allows.
  7. Withdraw slowly while injecting to treat the whole bed; final angiogram for TIMI flow and blush.

Prevent

  • Embolic protection and vasodilator pretreatment for vein graft PCI 31.
  • Lower rotational atherectomy speeds of 140,000 to 150,000 rpm and orbital at 80,000 rpm 2.
  • Clear the catheter after passing the aorta before injecting 2.
  • Aspiration and predilation of a STEMI culprit can themselves embolize plaque; weigh them case by case 2.

After care and documentation

  • ECG and troponin; echo for wall motion.
  • Document the TIMI flow before and after, the agents and total doses, and the delivery route.
  • Debrief: the lesion type, devices and what restored flow.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0015: Contrast crawls after deployment
  • EMG-0040: Contrast crawls after deployment
  • EMG-0065: The stent looks fine; the patient does not

References

  1. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 25, Acute vessel closure.
  3. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 18, Bypass grafts and prior CABG patients.
  4. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 14, Hemodynamic support.
  6. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/no-reflow. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.