PCI complications: coronary vasospasm

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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
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Treatment

• Intracoronary vasodilators should be given slowly through guiding catheters with side holes to maximize the delivery into the artery with minimal dispersal through the catheter side holes.
  • Intracoronary nitroglycerin 100-300 mcg. Generally well tolerated and have an additive effect.
  • Intracoronary calcium channel blockers. Generally well tolerated, have an additive effect, and have a small risk of transient heart block.
    • Diltiazem 0.5-2.5 mg/min, up to 5-10 mg
    • Verapamil 100 mcg/min, up to 1.0-1.5 mg
    • Nicardipine 100-300 mcg
    • Nifedipine 10 mg sublingual (SL)
  • Intracoronary nitroprusside 100-300 mcg
• Systemic vasodilators
  • Nifedipine 10 mg sublingual
  • Atropine 0.5 mg IV. Particularly useful in the setting of hypotension or bradycardia.
• Device related treatments
  • Removal of interventional hardware with guide wire in place to minimize mechanical provocation. This strategy may minimize distal vessel spasm.
  • Repeat prolonged (2-5 min) PTCA at low pressure (1-4 atmospheres). May mechanically "break" vasospasm.
  • Stenting. May improve focal spasm, but may simply propagate the site of spasm to a location proximal or distal to the stent within the vessel, so it should be avoided if possible.

• Therapeutic treatment of PCI-induced vasospasm should be performed in this order (step-wise fashion):

• Initial step is intracoronary vasodilatation with IC calcium channel blockers and/or nitrates, which should be given slowly when using guiding catheters with side holes to avoid dispersal of the drug through the holes instead of into the coronary artery.
• If one agent is unsuccessful, combined therapy should be implemented as these medications have an additive effect. Be mindful for heart block with CCB therapy.
• IV atropine can be useful if there is associated hypotension of bradycardia.
• Should medical therapy fail, remove all hardware and leave the guide wire in place to maintain position. This may minimize distal vessel spasm.
• Repeat prolonged PTCA for 2-5 minutes at low pressures (1-4 atmospheres).
• Stenting should be a last ditch option, and used if above measures have failed, as it may lead to propagation of spasm to a new location. Refractory vasospasm may be indicative of dissection, which is also an indication for stenting.

How To Know if Treatment of PCI-Induced Vasospam is Working

Therapies for vasospasm will usually take effect within seconds to one minute. Anticipated outcomes include:

• Resolution of acute or chronic coronary vasospasm
• Resolution of ECG changes (ST depression or elevation)
• Resolution of symptomatic angina and other symptoms, if present
• Repeat angiography