Should Aspiration Thrombectomy Be Performed in All, Most, or Few Primary PCI Procedures?

December 02, 2009

In This Article


In summary, aspiration thrombectomy with primary PCI appears to improve myocardial reperfusion and may improve clinical outcomes. Aspiration thrombectomy is relatively easy to perform and appears to be safe, but it does have limitations. Thrombus removal is often incomplete and passage of the catheter can sometimes result in distal embolization. Despite these limitations, it appears reasonable to perform manual thrombectomy with primary PCI in patients with moderate to large thrombus burden. Patients with little or no thrombus burden are not likely to benefit and probably do not need to be treated.

Glycoprotein IIb/IIIa platelet inhibitors have proven benefit with primary PCI and appear to be beneficial in patients with large thrombus burden. The Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial is changing the paradigm for antithrombotic therapy with primary PCI, with the use of bivalirudin in place of unfractionated heparin and glycoprotein IIb/IIIa inhibitors.[10] However, large thrombus was an exclusion in the HORIZONS-AMI trial, and glycoprotein IIb/IIIa platelet inhibitors are indicated in this situation.

The management of thrombus burden in STEMI patients treated with primary PCI remains a challenge. New thrombectomy devices that retain the ease of use of aspiration catheters, but provide more effective thrombus removal are needed. The use of intracoronary administration of glycoprotein IIb/IIIa platelet inhibitors has improved myocardial reperfusion in small pilot trials and should be tested in larger trials.[11] Large randomized trials with aspiration thrombectomy or newer generation thrombectomy devices, which are powered for clinical endpoints and possibly focused on patients with moderate or large thrombus burden, are needed to determine the optimum adjunctive therapy for managing thrombotic lesions in STEMI patients treated with primary PCI.


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