PCI complications: coronary vasospasm

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

Overview

Coronary vasospasm can be induced by percutaneous coronary intervention (PCI) secondary to endothelial denudation and nitric oxide loss. The main goal of the treatment is to reverse angioplasty-induced vasospasm. The initial treatment is intracoronary vasodilatation with calcium channel blockers and/or nitrates, which should be given slowly when using guiding catheters. Therapies for vasospasm will usually take effect within seconds to one minute.

Classification

Focal coronary spasm

Focal coronary spasm is limited to a localized segment of the coronary artery.

Multifocal coronary spasm

Multifocal coronary spasm involves several localized segments of the same coronary artery.

Multivessel coronary spasm

Multivessel coronary spasm involves several coronary arteries.[1][2]

Pathophysiology

  • Coronary vasospasm can be induced by PCI secondary to endothelial denudation and nitric oxide loss.
  • Some cases are catheter-induced which is caused by a contact of a catheter without balloon deployment. Catheter-induced coronary vasospasm is usually short-lived.
  • Catheter-induced coronary vasospasm is most prone to occur at the ostium of the right coronary artery (RCA). The left main is less susceptible to ostial spasm.

Differential Diagnosis

Epidemiology and Demographics

  • Coronary vasospasm can occasionally be induced by PCI.
  • Rotablator cases are more prone to coronary vasospasm. The reported incidence of rotablator cases with coronary vasospasm ranges anywhere from 4 to 36%.

Risk factors

Smoking is a risk factor for coronary vasospasm.

Natural History, Complications and Prognosis

Diagnosis

  • Physicians should suspect coronary vasospasm if ST segment elevation is detected in patients experiencing angina, and if the ECG completely returns to baseline upon resolution of symptoms.
  • The definitive diagnosis of coronary vasospasm is made angiographically by demonstration of reduction of luminal diameter in a discrete segment of the vessel, which is proven to be reversible.
  • Reversibility may be demonstrated by previous or subsequent enlargement of luminal diameter, often after the administration of intracoronary vasodilators.

Treatment

Choices of Treatment

Intracoronary Vasodilator

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.

Systemic Vasodilators

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.

Step by Step Treatment Approach

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

Assessment of Response to Therapy

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

References

  1. Ahooja V, Thatai D (2007). "Multivessel coronary vasospasm mimicking triple-vessel obstructive coronary artery disease". J Invasive Cardiol. 19 (7): E178–81. PMID 17620681. 
  2. Miwa K, Ishii K, Makita T, Okuda N (2004). "Diagnosis of multivessel coronary vasospasm by detecting postischemic regional left ventricular delayed relaxation on echocardiography using color kinesis". Circ. J. 68 (5): 483–7. PMID 15118293. 



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