The no-flow phenomenon during diagnostic coronary angiography

Objectives: Slow flow of dye in epicardial coronary arteries is not an infrequent finding in patients during routine coronary angiography. The extreme form of this phenomenon, namely, no flow or Thrombolysis in Myocardial Infarction (TIMI) 0-1, is very uncommon with life-threatening consequences. We consider the present report as the first one, to our knowledge, that describes this angiographic entity and how prompt recognition and adequate management prevent certain death in this population. Design, setting, and patients: Retrospective review of the cardiac catheterization laboratory database at our medical center. Out of 5700 cardiac catheterizations performed by the authors during the past 5 years, 10 cases (0.17%) were identified as having no flow or very slow flow during their routine diagnostic coronary angiogram. Case analysis: The no-flow phenomenon occurred during the first coronary injection in the left coronary system. We specifically emphasize that none of these cases was a consequence of inadvertent air injection, vasospasm, or coronary dissection. In 80% of our cases, flow was completely absent (TIMI 0), and in two cases (20%) it was very slow and never filling the distal vessel (TIMI 1). Despite immediate recognition and prompt maneuvers and treatment with intracoronary vasodilator administration, 60% of these patients progressed to full cardiopulmonary arrest with all of them having extended cardiopulmonary resuscitation (CPR) and pharmacological treatment. Only one patient required intra-aortic balloon pump (IABP) support and temporary pacemaker. All patients recovered completely with no clinical consequences. Characteristics of patients with this complication are described, and several possible etiologies are analyzed. Conclusions: Definite conclusions for the reason of the no-flow phenomenon are not possible at present, despite multiple different theories that could explain it. What is important from the clinical standpoint is that, although rare, it is a potentially life-threatening condition during diagnostic coronary angiography that should be recognized and aggressively treated. We consider the present report as the first one, to our knowledge, that describes this angiographic entity, and how prompt recognition and adequate management prevents certain death in this population. (C) 2005 Elsevier Inc. All rights reserved.