Thrombus Aspiration during Primary PCI Does Not Improve Clinical Outcomes

Thrombus aspiration during primary PCI in ST elevation MI has been extensively used; however, recent studies have questioned its efficacy and safety.

This meta-analysis looked into individual patient data to determine the benefit and safety of thrombus aspiration during primary PCI.

It included all randomized and controlled studies assessing manual thrombectomy vs. conventional primary PCI including more than 1.000 patients undergoing ST elevation MI. Individual patient data was provided by the lead researchers of each study.

Efficacy primary end point was cardiovascular mortality at 30 days and safety primary end point was any stroke or transient ischemic attack also at 30 days.

The 3 eligible studies (TAPAS, TASTE and TOTAL) enrolled 18,306 patients receiving primary PCI with available data.

Cardiovascular death at 30 days occurred in 221 patients (2.4%) out of 9,155 randomized to thrombectomy and in 262 (2.9%) of those randomized to primary PCI alone (HR: 0.84; CI 95%; p=0.06).

Stroke and transient ischemic attack occurred in 66 patients (0.8%) among those randomized to manual thrombectomy compared to 46 (0.5%) in the group of primary PCI alone (OR: 1.43 IC 0.98-2.1; p=0.06).

There were no significant differences in repeat MI rate, stent thrombosis, cardiac failure, or target vessel revascularization.

When studying the subgroup with high thrombotic load separately, thrombus aspiration was associated to lower cardiovascular death (2.5% vs. 3.1%, HR 0.80; p=0.03) but higher stroke or transient ischemic attack (0.9% vs. 0.5%, p=0.04). Despite these rates, the interaction p value was 0.32 and 0.34, respectively.

Conclusion

Routine thrombus aspiration during primary PCI does not improve clinical outcomes. In the subgroup of patients with high thrombotic load, there was a tendency to lower mortality and higher stroke rates, which provides the rationale for future studies.

Editorial Comment

The AHA/ACC 2015 guidelines state the use of thrombus aspiration in the context of primary PCI is IIb/C for cases with intra-luminal thrombus, and class III for routine use, in all cases. 

To date, the existing literature does not support the routine use of thrombus aspiration in the management of ST elevation acute myocardial infarction. Operators might consider the benefit of this technique is potentially higher than its risks on a case by case basis.

Original Title: Thrombus Aspiration in ST Elevation Myocardial Infarction: An Individual Patient Meta-analysis.

Reference: Sanjit S. Jolly et al. Circulation 2016 Dec 9. [Epub ahead of print].

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