Distal vessel pullback angiography and pressure gradient measurement: an innovative diagnostic approach to evaluate the no-reflow phenomenon.

The angiographic appearance of "no-reflow" in saphenous vein grafts or native coronary arteries has been described following administration of thrombolytic therapy or performance of percutaneous transluminal coronary angioplasty or atherectomy. Apparent occlusion may represent spasm, dissection, thrombosis, or competitive collateral circulation, all of which must be excluded to make the diagnosis of "no-reflow." We describe an innovative approach to the diagnostic dilemma created by the appearance of "no-reflow" at coronary angiography. Pressure gradient measurement with distal vessel pull-back (retrograde) angiography provides maximal information regarding the severity of disease and the etiology of "no-reflow," while exposing both the patient and angiographer to less risk compared to standard strategies.