Coronary artery dissections, perforations, and the no-reflow phenomenon

Coronary dissection, perforation, and the no-reflow phenomenon are some of the most dreaded complications occurring in the catheterization laboratory and have been associated with a high rate of major adverse outcomes. This chapter discusses the risk factors, recognition, and contemporary approach to managing peri-procedural complications related to percutaneous coronary intervention (PCI). Ischemic complications in the current era usually occur as manifestations of edge dissections after metallic stent or bioresorbable vascular scaffold (BVS) implantation, which can predispose to device thrombosis. Intramural hematoma is a variant of dissection. By intracoronary ultrasound (IVUS) or optical coherence tomography (OCT), intramural hematomas are typically crescent-shaped, with straightening of the internal elastic membrane. For coronary perforation, the treatment strategy depends on the type of vessel and the location of the injury. Persistent no-reflow has important prognostic implications and has been associated with unfavorable clinical outcomes.