Abrupt closure during coronary intervention: Difference between revisions

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Latest revision as of 13:00, 17 June 2020

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]

Clinical: unstable angina, female, AMI, chronic renal failure
Angiographic: Intraluminal thrombus, ACC/AHA score, multivessel disease, long lesions, >45 degree angulation, branch points, proximal tortuosity, ostial RCA, degenerated SVGs, prestenosis >90%, intimal dissections

Natural History, Complications and Prognosis

Factors predicting mortality after abrupt closure are as follows:

% myocardium at risk
LM and multivessel disease
CHF, UAP
Target vessels supplies collaterals
> age 65 years
Chronic renal failure
Female gender
Diabetes

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

References

↑ 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.

Template:WH Template:WS CME Category::Cardiology

[pmid11870931-1] 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.

[1]

@@ Line 1: / Line 1: @@
-{{SI}}
+__NOTOC__
+{{PCI}}
+'''Editor(s)-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]  {{AE}} {{HP}}, {{Sapan}}
-{{CMG}}
+==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 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==
+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 stent]]s.
+==Risk Factors<ref name="pmid11870931">{{cite journal| author=Suh WW, Grill DE, Rihal CS, Bell MR, Holmes DR, Garratt KN| title=Unrestricted availability of intracoronary stents is associated with decreased abrupt vascular closure rates and improved early clinical outcomes. | journal=Catheter Cardiovasc Interv | year= 2002 | volume= 55 | issue= 3 | pages= 294-302 | pmid=11870931 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11870931  }} </ref>==
+*Clinical: [[unstable angina]], female, [[AMI]], [[chronic renal failure]]
+*[[Angiographic]]: [[Intraluminal]] [[thrombus]], ACC/AHA score, [[multivessel coronary artery disease|multivessel disease]], long [[lesion]]s, >45 degree angulation, branch points, [[proximal]] [[tortuosity]], ostial [[RCA]], degenerated [[SVG]]s, pre[[stenosis]] >90%, [[intimal]] [[dissection]]s
+==Natural History, Complications and Prognosis==
+Factors predicting mortality after abrupt closure are as follows:
+*% [[myocardium]] at risk
+*LM and [[multivessel coronary artery disease|multivessel disease]]
+*[[CHF]], [[UAP]]
+*Target [[vessel]]s supplies [[collateral]]s
+*> age 65 years
+*[[Chronic renal failure]]
+*Female gender
+*[[Diabetes]]
+==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==
+===[[Abrupt closure case 1|Case 1]]===
+===[[Abrupt closure case 2|Case 2]]===
+===[[Abrupt closure case 3|Case 3]]===
+===[[Abrupt closure case 4|Case 4]]===
+===[[Abrupt closure case 5|Case 5]]===
+===[[Abrupt closure case 6|Case 6]]===
+===[[Abrupt closure case 7|Case 7]]===
+===[[Abrupt closure case 8|Case 8]]===
+===[[Abrupt closure case 9|Case 9]]===
+===[[Abrupt closure case 10|Case 10]]===
+===[[Abrupt closure case 11|Case 11]]===
+===[[Abrupt closure case 12|Case 12]]===
+===[[Abrupt closure case 13|Case 13]]===
+===[[Abrupt closure case 14|Case 14]]===
-==Overview==
+===[[Abrupt closure case 15|Case 15]]===
-Abrupt closure is defined as the development of TIMI grade 0 or 1 flow during percutaneous coronary intervention (PCI).  If a patient begins the procedure with TIMI grade 0 or 1 flow, the term abrupt closure is applied if during some point in the procedure there was restoration of TIMI grade 3, which was followed by a recurrence of TIMI grade 0 or 1 flow.
+===[[Abrupt closure case 16|Case 16]]===
+===[[Abrupt closure case 17|Case 17]]===
+===[[Abrupt closure case 18|Case 18]]===
+===[[Abrupt closure case 19|Case 19]]===
+===[[Abrupt closure case 20|Case 20]]===
+===[[Abrupt closure case 21|Case 21]]===
+===[[Abrupt closure case 22|Case 22]]===
+===[[Abrupt closure case 23|Case 23]]===
+===[[Abrupt closure case 24|Case 24]]===
+===[[Abrupt closure case 25|Case 25]]===
+===[[Abrupt closure case 26|Case 26]]===
-[[Category:Cardiology]]
+===[[Abrupt closure case 27|Case 27]]===
+===[[Abrupt closure case 28|Case 28]]===
+===[[Abrupt closure case 29|Case 29]]===
+==References==
+{{reflist|2}}
 {{WH}}
+{{WS}}
+[[CME Category::Cardiology]]
-{{WS}}
+[[Category:Cardiology]]
+[[Category:Angiopedia]]
+[[Category:Up-To-Date]]
+[[Category:Up-To-Date cardiology]]