Very Effective Distal Adenosine Administration of Very High Doses using Export Catheter for the Treatment of Resistant and Persistent No-reflow in LAD
Presenter
Mohammad-Reza Movahed, MD, University of Arizona College of Medicine – Tucson, Tucson, AZ, United States of America
Mohammad-Reza Movahed, MD, University of Arizona College of Medicine – Tucson, Tucson, AZ, United States of America
Title
Very effective Distal Adenosine Administration of Very High Doses using Export Catheter for the Treatment of Resistant and Persistent No-reflow in LAD Introduction
Resistant no-reflow can be difficult to treat. Unfortunately, persistent no-reflow can increase cardiac adverse events. It can be very difficult to treat. Intracoronary injections of any vasoactive substances into the proximal coronaries cannot efficiently infuse the distal coronary bed. In this case, we report distal administration of very high doses of Adenosine in a native coronary artery for a severe life-threatening resistant no-reflow. Using an export catheter, we could reverse this complication within seconds.
Clinical Case
A 69-year-old presented with inferior ST-elevation myocardial infarction. The patient was taken urgently to the cath lab with stenting to distally occluded RCA. His left anterior descending artery (LAD) had two 80-90% mid lesions . He was brought back for procedure on his LAD. A Balance Middle Weight 0.014-inch wire was used . An Emerge 2.0 mm x 12 balloons was inflating to 8-10 atmospheres. A Synergy 2.5 x 16 stent was deployed at 18 atm. Post-stenting, severe no-reflow occurred with severe chest pain . Multiple doses of 80 micrograms of intracoronary adenosine administration did not cause any improvement in the flow with worsening chest pain. The patient was restless with severe chest pain and significant EKG changes. The decision was made to proceed with the distal administration of a very high dose of adenosine. An export thrombectomy catheter was advanced into mid-LAD within seconds with the administration of 500 micrograms of Adenosine distally with immediate normalization of distal flow. The patient developed transient ventricular fibrillation due to reperfusion arrhythmia which was successfully cardioverted. The patient remained chest pain-free. and was discharged the next day
Discussion
No-reflow is a serious condition that increases adverse outcomes. It requires immediate attention. Unfortunately, many ac=vailable treatments can fail to reverse persistent no-reflow. However, distal administration of very high doses of adenosine with the availability of an export catheter can be performed very easily and quickly in less than 20 seconds. Distal vasoactive substance administration has been successfully reported in limited case reports but totally underutilized. We reported the first successful case in 2008 before the availability of export catheter using an over-the-balloon catheter which is more time-consuming and requires wire extension. Recently, a Clearway catheter (Atrium Medical, Hudson, NH) which is a rapid exchange balloon catheter has been successfully used for this purpose. T We believe that this approach should be the standard of care in resistant no reflows. Due to the very short half-life of adenosine and distal administration of this drug, multiple very high doses can be administered safely. Other vasoactive drugs can also be given with this approach. Randomized clinical trials hopefully can assess the safety and effectiveness of this approach. With this manuscript, we hope that we can raise the awareness of our interventional community about this approach for treating resistant no-reflow. Furthermore, we emphasize that the utilization of an export catheter appears to be the easiest method for this treatment option.