Document Type : Research articles


Medical Doctor, Assistant Professor, Selcuk University, Faculty of Medicine, Department of Cardiology, Konya, Turkey


Background: Although numerous mechanisms regarding the no-reflow phenomenon (NRP) have been mentioned, they have not yet been fully elucidated. The NRP can impact the success rate even in a technically flawless percutaneous coronary intervention (PCI), which can be annoying. Before the procedure, there is no specific parameter or index that can assess a significant factor such as NRP that has a direct impact on the success of the PCI.Objectives: The present study aimed to evaluate the relationship between the systemic immune-inflammation index (SII) and NRP in patients who underwent PCI for saphenous vein graft (SVG).Methods: In this retrospective cohort study, 312 coronary artery bypass grafting (CABG) patients admitted to primary or elective SVG and those who underwent PCI between January 2014 and December 2021 were selected. Routine blood samples were taken from the patients at the time of admission, and SII was calculated as the ratio of the product of the total neutrophil count and the total platelet count to the lymphocyte count. The reperfusion rates after PCI were evaluated according to the thrombolysis in myocardial infarction (TIMI) grade flow and myocardial blush grade (MBG). Following the procedure, those with an angiographic TIMI flow grade of ? 2 or TIMI flow grade of 3 and a final MBG of < 2 were considered NRP.Results: The number of 85 patients (27.2%) were diagnosed with NRP. The SII and ST-elevation myocardial infarction were found to be independent predictors for NRP in multivariate logistic regression analysis (P<0.05). The SII predicted NRP with a sensitivity of 86% and a specificity of 80% (AUC: 0.866, 95% CI: 0.823 to 0.910, P<0.001) using a cut-off point of 13.45.Conclusion: The SII is an independent predictor that can be easily calculated from the whole blood test to predict no-reflow development, which is a frustrating complication in patients following the PCI to the saphenous vein. This predictor can enable us to pre-evaluate the non-operational reasons affecting the procedure's success.


  1. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(23):e652-735. doi: 10.1161/CIR.0b013e31823b5fee. Epub 2011 Nov 7. [PubMed: 22064600].
  2. Harskamp RE, Lopes RD, Baisden CE, de Winter RJ, Alexander JH. Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions. Annals of surgery. 2013;257(5):824-33. doi: 10.1097/SLA.
  3. b013e318288c38d. [PubMed: 23574989].
  4. Eid-Lidt G, Gaspar J, Adames AE, Damas de Los Santos F, Valdez RI, Ramirez-Gutierrez AE, et al. Long-term outcomes of saphenous vein graft stenting compared with native coronary artery stenting in patients with previous coronary artery bypass graft surgery. Arch Cardiol Mex. 2010;80(1):3-9. [PubMed: 21147555].
  5. Özen Y, Özbay MBJERfM, Sciences P. Assessment of systemic immune-inflammation index as an independent surrogate biomarker of no-reflow phenomenon in acute coronary syndrome patients with coronary artery bypass grafting undergoing percutaneous coronary intervention of saphenous vein graft. Rev Med Pharmacol Sci. 2023;27(6):2394-403. doi: 10.26355/eurrev_202303_31774. [PubMed: 37013758].
  6. Kanal Y, Şeyda KANAL HE, Yakut I, Özen Y, Özbay MB, Gülcihan BALCI K, et al. CRP Albumin Ratio May Predict No Reflow in Patients Undergoing Percutaneous Coronary Intervention for Saphenous Vein Graft Stenosis. Angiology. 2023;74(1):55-61. doi: 10.1177/00033197221098277. [PubMed: 35500071].
  7. Lee MS, Park SJ, Kandzari DE, Kirtane AJ, Fearon WF, Brilakis ES, et al. Saphenous vein graft intervention. JACC Cardiovasc Interv. 2011;4(8):831-43. doi: 10.1016/j.jcin.2011.05.014. [PubMed: 21851895].
  8. Soverow J, Lee MSJJIC. Saphenous vein graft intervention: Status report 2014. J Invasive Cardiol. 2014;26(12):659-67. [PubMed: 25480996].
  9. Salinas P, Jimenez-Valero S, Moreno R, Sanchez-Recalde A, Galeote G, Calvo L, et al. Update in pharmacological management of coronary no-reflow phenomenon. Cardiovasc Hematol Agents Med Chem. 2012;10(3):256-64. doi: 10.2174/
  10. [PubMed: 22827250].
  11. Hu B, Yang XR, Xu Y, Sun YF, Sun C, Guo W, et al. Systemic immune-inflammation index predicts prognosis of patients after curative resection for hepatocellular carcinoma. Clin Cancer Res. 2014;20(23):6212-22. doi: 10.1158/1078-0432.CCR-14-0442. [PubMed: 25271081].
  12. Huang J, Zhang Q, Wang R, Ji H, Chen Y, Quan X, et al. Systemic Immune-Inflammatory Index Predicts Clinical Outcomes for Elderly Patients with Acute Myocardial Infarction Receiving Percutaneous Coronary Intervention. Med Sci Monit. 2019;25:9690-701. doi: 10.12659/MSM.919802. [PubMed: 31849367].
  13. El-Menyar A, Zubaid M, AlMahmeed W, Sulaiman K, AlNabti A, Singh R, et al. Killip classification in patients with acute coronary syndrome: insight from a multicenter registry. Am J Emerg Med. 2012;30(1):97-103. doi: 10.1016/j.ajem.2010.
  14. 011. [PubMed: 21159479].
  15. Kelesoglu S, Yilmaz Y, Elcık D, Çetınkaya Z, Inanc MT, Dogan A, et al. Systemic Immune Inflammation Index: A Novel Predictor of Contrast-Induced Nephropathy in Patients With Non-ST Segment Elevation Myocardial Infarction. Angiology. 2021;72(9):889-95. doi: 10.1177/00033197211007738. [PubMed: 33827291].
  16. Butler MJ, Chan W, Taylor AJ, Dart AM, Duffy SJ. Management of the no-reflow phenomenon. Pharmacol Ther. 2011;132(1):72-85. doi: 10.1016/j.pharmthera.2011.05.010. [PubMed: 21664376].
  17. Hashemi-Jazi M, Hosseini SM, Gholamrezaei A. Factors associated with the no-reflow phenomenon following percutaneous intervention of saphenous vein coronary bypass grafts. ARYA Atheroscler. 2017;13(5):221-9. [PubMed: 29371868].
  18. Maksimenko AV, Turashev AD. No-reflow phenomenon and endothelial glycocalyx of microcirculation. iochem Res Int. 2012;2012:859231. doi: 10.1155/2012/859231. [PubMed: 22191033].
  19. Zhao B, Li J, Luo X, Zhou Q, Chen H, Shi H. The role of von Willebrand factor and ADAMTS13 in the no-reflow phenomenon: after primary percutaneous coronary intervention. Tex Heart Inst J. 2011;38(5):516-22. [PubMed: 22163125].
  20. Esenboğa K, Kurtul A, Yamantürk YY, Tan TS, Tutar DE. Systemic immune-inflammation index predicts no-reflow phenomenon after primary percutaneous coronary intervention. Acta Cardiol. 2022;77(1):59-65. doi: 10.1080/
  21. 2021.1884786. [PubMed: 33612077].
  22. Zhang Q, Hu M, Sun J, Ma S. The combination of neutrophil-to-lymphocyte ratio and platelet correlation parameters in predicting the no-reflow phenomenon after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. Scand Cardiovasc J. 2020;54(6):352-7. doi: 10.1080/14017431.2020.1783457. [PubMed: 32597237].
  23. Wang Z, Ren L, Lei L, Ye H, Peng J. The relationship between neutrophil counts on admission and angiographic no-reflow after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. Acta Cardiol. 2016;71(2):241-6. doi: 10.2143/AC.71.2.3141856. [PubMed: 27090048].
  24. Dogan NB, Ozpelit E, Akdeniz S, Bilgin M, Baris N. Simple clinical risk score for no-reflow prediction in patients undergoing primary Percutaneous Coronary Intervention with acute STEMI. Pak J Med Sci. 2015;31(3):576-81. doi: 10.12669/pjms.313.7484. [PubMed: 26150847].
  25. Kocas C, Abaci O, Arslan S, Bostan C, Coskun U, Akturk F, et al. The association of neutrophil to lymphocyte ratio and TIMI frame count in primary percutaneous coronary intervention. Minerva Cardioangiol. 2019;67(6):471-6. doi: 10.23736/
  26. S0026-4725.16.03745-2. [PubMed: 25881873].
  27. Engelmann B, Massberg S. Thrombosis as an intravascular effector of innate immunity. Nat Rev Immunol. 2013;13(1):34-45. doi: 10.1038/nri3345. [PubMed: 23222502].
  28. Maden O, Çakmak Karaaslan Ö, Kanal Y, Yakut I, Yaman NM, Könte HC, et al. Association of CHA2DS2-VASc score with thrombus burden in patients with acute myocardial infarction undergoing SVG-PCI. Herz. 2022;47(5):456-64. doi: 10.1007/s00059-021-05070-x. [PubMed: 34608522].
  29. Huang Y, Gao Y, Wu Y, Lin H. Prognostic value of systemic immune-inflammation index in patients with urologic cancers: a meta-analysis. Cancer Cell Int. 2020;20:499. doi: 10.1186/s12935-020-01590-4. [PubMed: 33061851].
  30. Erdoğan M, Erdöl MA, Öztürk S, Durmaz T. Systemic immune-inflammation index is a novel marker to predict functionally significant coronary artery stenosis. Biomark Med. 2020;
  31. (16):1553-61. doi: 10.2217/bmm-2020-0274. [PubMed: 33179524].
  32. Erdoğan M, Öztürk S, Kardeşler B, Yiğitbaşı M, Kasapkara HA, Baştuğ S, et al. The relationship between calcific severe aortic stenosis and systemic immune-inflammation index. Echocardiography. 2021;38(5):737-44. doi: 10.1111/echo.
  33. [PubMed: 33772853].
  34. Kelesoglu S, Yilmaz Y, Elcık D, Kalay N. Systemic immune inflammation index: a novel predictor for coronary collateral circulation. Perfusion. 2022;37(6):605-12. doi: 10.1177/0267
  35. [PubMed: 33960235].
  36. Ertem AG, Ozen Y, Yuksekkaya B, Akif Erdol M, Erdoğan M, Demirtas K, et al. Association of the Novel Inflammatory Marker Systemic Immune-Inflammation index and Contrast-Induced Nephropathy in Patients Undergoing Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis. Angiology. 2022;73(5):422-30. doi: 10.1177/00033197211
  37. [PubMed: 35057646].