Interventional cardiology

More evidence against routine thrombosis aspiration before PCI

The use of thrombus aspiration in patients undergoing primary PCI for STEMI is not associated with improved short or long-term mortality when compared with PCI alone.

In a Melbourne study of 6,270 consecutive patients undergoing primary PCI for STEMI between 2007 and 2018, 26% of the cohort underwent manual intracoronary thrombus aspiration (TA) prior to their PCI.

TA was performed at the discretion of the treating interventionalist with Export AP aspiration catheters (Medtronic) the most commonly used device.

The study, published in the Internal Medicine Journal, found a reduction in recurrent MI (0.7 v 1.6%, p<0.01) and MACE (7.9 v 10.0%, p=0.01) in the TA group compared to the PCI-alone group.

However, in-hospital major bleeding events were higher in the TA group (5.8 vs 4.4%, p=0.02).

Other in-hospital outcomes including all-cause mortality, new onset heart failure and peri-procedural stroke were not significantly different between the two groups.

At 30 days, recurrent MI (1.2 v 2.4%, p<0.01), target vessel revascularisation (2.3 v 3.9%, p<0.01), target lesion revascularisation (1.9 v 3.5%, p <0.01), and MACCE (9.6 v 12.7%, p<0.01) were all lower in the TA group.

There was no difference in 30-day rates of stroke (0.9 v 1.0%, p=0.88), 30-day mortality (6.7 vs. 7.7%, p=0.17) or long-term mortality (17 v 17%, p=0.96).

The study authors, from the Melbourne Interventional Group, said their mortality finding was consistent with previous RCTs and retrospective studies.

“Although results from other registries have been varied, our findings support the 2015 changes to thrombectomy guidelines published by the European Society of Cardiology and the American College of Cardiology/American Heart Association that routine manual TA should not be performed unless there are clinical and angiographic characteristics which suggest there would be a benefit.”

They said dual anti-platelet therapy and possibly glycoprotein IIb/IIIa inhibitors may be alternatives to TA in patients with a high thrombus burden.

“Supporting this, we observed that the use of glycoprotein IIb/IIIa inhibitors was associated with lower 30-day MACCE, similar to results of previous studies including the INFUSE-AMI trial.”

Lead author Dr Kevin Rajakariar, from the department of cardiology at Eastern Health, told the limbic that while the study suggested there wasn’t a role for routine TA, there was still a potential role for selective use of TA.

Patients in cardiogenic shock or with difficult or complex lesions were the likely patients to benefit.

He noted that one of the limitations with the study was the risk of selection bias from the operators in choosing sicker patients and those with complex lesions for TA.

“When the lesions look a lot more complicated, and it might be difficult to put in the balloons or stents, we would consider trying to aspirate the clot out. There are always risks associated with this and the big one was whether trying to suck out the clot from the coronary arteries would lead to an increased risk of stroke. However… we found that there was no difference in the rates of stroke.”

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