What is your stepwise approach to managing no re-flow during PCI?

It’s not so much the vasodilator cocktail, as much as it is, getting the vasodilator cocktail into the capillary bed. This is best achieved by very distal injection via any thrombectomy catheter (which can also be used for thrombectomy if needed). Adenosine at 24 mcg/cc + nicardipine (or verapamil) 100 mcg/cc + NTG 100 mcg/cc is a reasonable ‘cocktail’.

Adenosine is delivered to the distal coronary with a Pronto catheter (easy to use and available if aspiration is also necessary). Rarely use it otherwise. Then Verapamil and NTG (it is already at the table for a radial cocktail, even though NTG is for epicardial spasm). Nitroprusside next.

Verapamil or nitroprusside IC, depending on presentation. Aspiration thrombectomy if the latter is ineffective.

If the above-mentioned usual options are not effective, and if hypotension and/or bradycardia are also present, there is growing evidence to support the use of IC Epinephrine. A small study showed IC Epi lead to a higher rate of TIMI III flow compared to IC Adenosine in a normotensive ACS population. (Khan et al., PMID 35000456). A systematic review showed that IC Epi can be effective and safe as well. (Jafari Afshar et al., PMID 36852839). I have found IC Epi to be a difference maker in some of the more difficult no reflow cases.