Abrupt closure during coronary intervention

# Overview
Abrupt closure during coronary intervention is defined as an abrupt cessation of coronary flow to TIMI grade 0 or 1 flow before or at 5 mm distal to the lesion in an artery in which PTCA was attempted where there had previously been TIMI grade 2 or 3 flow prior to the procedure. It occurs primarily due to acute coronary dissection, thrombosis, or, most often, a combination of both during coronary intervention.

# Definition
Abrupt closure during coronary intervention is defined as an abrupt cessation of coronary flow to TIMI grade 0 or 1 flow before or at 5 mm distal to the lesion in an artery in which PTCA was attempted where there had previously been TIMI grade 2 or 3 flow prior to the procedure. If TIMI flow grade 1 was present prior to dilation, then the development of TIMI flow grade 0 will constitute abrupt closure. In cases in which the artery being dilated had TIMI flow grade 0 prior to the procedure, if TIMI flow grade 2 or 3 is achieved during the procedure, and if the procedure is completed with TIMI flow grade 0, then this will also constitute abrupt closure. The table below outlines the possible scenarios that would be classified as abrupt closure:

# Classification
Abrupt closure can be classified as sustained or transient:
- Sustained abrupt closure: Abrupt closure that has been present when the patient left the cardiac catheterization laboratory.
- Transient abrupt closure: Abrupt closure that has been treated with restoration of coronary blood flow to TIMI flow grade 2 or 3 before the patient left the cardiac catheterization laboratory.

# Causes
Abrupt closure occurs primarily as a result of acute coronary dissection, thrombosis, intracoronary spasm, embolization, intra-procedural stent thrombosis or, most often, a combination of all the above during coronary intervention.

# Epidemiology and Demographics
It occurs during 3-5% of balloon angioplasty procedures. Its incidence has been markedly reduced with the availability of coronary stents.

# Risk Factors
- Clinical: unstable angina, female, AMI, chronic renal failure
- Angiographic: Intraluminal thrombus, ACC/AHA score, multivessel disease, long lesions, >45 degree angulation, branch points, proximal tortuosity, ostial RCA, degenerated SVGs, prestenosis >90%, intimal dissections

# Natural History, Complications and Prognosis
Factors predicting mortality after abrupt closure are as follows:
- % myocardium at risk
- LM and multivessel disease
- CHF, UAP
- Target vessels supplies collaterals
- > age 65 years
- Chronic renal failure
- Female gender
- Diabetes

# Treatment
- Intracoronary imaging as necessary to evaluate the cause
- Intracoronary stent placement to treat dissection
- Intracoronary vasodilators to treat epicardial vessel and microvascular spasm
- Imaging, additional dilation, anticoagulation and antiplatelets to treat intraprocedural stent thrombosis

# Abrupt Closure Examples

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