What is the role of thrombectomy in percutaneous coronary intervention (PCI)?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

In addition to balloons, stents, and atherectomy devices, other devices, such as thrombus extraction catheters and distal embolic protection devices, play a role in PCI.

In the TAPAS (Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction) trial, thrombus aspiration with an Export catheter before stenting yielded reductions in all-cause mortality (4.7% vs 7.6%) and cardiac death (3.6% vs 6.7%) at 1 year as compared with conventional PCI. [68]

In a pooled analysis of data from three prospective randomized trials, De Vita et al found that although increasing time to treatment was associated with a decreased rate of optimal reperfusion in patients receiving standard PCI, this trend was not seen in patients treated with thrombus aspiration. [69] The investigators concluded that the use of thrombus aspiration limits the adverse effects that prolonged time to treatment has on myocardial reperfusion.

The TASTE (Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia) trial randomly assigned 7244 STEMI patients to undergo manual thrombus aspiration followed by PCI or to undergo PCI alone. [70] At 30 days, there was no significant difference in all-cause mortality between the thrombus aspiration group (2.8%) and the PCI-only group (3%). At 30 days, the rates of hospitalization for recurrent MI were 0.5% and 0.9% in the two groups, respectively, and the rates of stent thrombosis were 0.2% and 0.5%, respectively.

When followed out to 1 year, the TASTE trial showed that routine thrombus aspiration before PCI in STEMI patients did not significantly reduce the rate of death from any cause or the composite of death from any cause, rehospitalization for MI, or stent thrombosis at 1 year. [71]

In TOTAL (Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI), the largest trial on routine thrombus aspiration, 10,732 patients with STEMI were randomly assigned to upfront manual aspiration thrombectomy or PCI alone. [72] There were no differences between the two groups with respect to cardiovascular death, recurrent MI, cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within 180 days. The rates of stent thrombosis or target-vessel revascularization were also similar.

As suggested in a previous meta-analysis, the thrombectomy group had a higher incidence of stroke within 30 days: 0.7% in the thrombectomy group versus 0.3% in the PCI-alone group (hazard ratio, 2.06; 95% CI, 1.13-3.75; P = 0.02). [72] Interestingly, there was a continued increase in strokes even at 30 days and 180 days in the thrombectomy group, which could not be easily explained and could also be a matter of chance. The subgroup analysis showed no benefit in heavy thrombus burden, TIMI 0-1 flow, or anterior infarcts.

A meta-analysis of these three thrombectomy trials showed no benefit of routine aspiration thrombectomy with respect to death, reinfarction, or stent thrombosis. There was small but nonsignificant increase in stroke with thrombectomy. [73]

In the 2016 update of STEMI guidelines from ACC/AHA/SCAI, routine aspiration thrombectomy was no longer recommended before primary PCI. The level of recommendation was changed from class IIa to class III. Because of insufficient data, “bailout” thrombectomy was a class IIb recommendation. [74]


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