Thrombus aspiration in ST-elevation myocardial infarction in Sweden

Abstract

Percutaneous coronary intervention (PCI) with balloon angioplasty and stenting is the optimal therapy in ST-segment elevation myocardial infarction (STEMI). While this treatment alleviates the major acute problem of having an occluded or highly stenosed coronary artery, distal embolization of thrombus material and other debris often precludes restoration of normal coronary artery flow [ [1] Henriques J.P. Zijlstra F. Ottervanger J.P. et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J. 2002; 23: 1112-1117 Crossref PubMed Scopus (553) Google Scholar ]. Thrombus aspiration may contribute to improve coronary artery flow post PCI [ 2 Sardella G. Mancone M. Bucciarelli-Ducci C. et al. Thrombus aspiration during primary percutaneous coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct-related artery during primary percutaneous coronary intervention) prospective, randomized trial. J Am Coll Cardiol. 2009; 53: 309-315 Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar , 3 Svilaas T. Vlaar P.J. van dH I. et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med. 2008; 358: 557-567 Crossref PubMed Scopus (884) Google Scholar , 4 Ikari Y. Sakurada M. Kozuma K. et al. Upfront thrombus aspiration in primary coronary intervention for patients with ST-segment elevation acute myocardial infarction: report of the VAMPIRE (VAcuuM asPIration thrombus REmoval) trial. JACC Cardiovasc Interv. 2008; 1: 424-431 Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar , 5 Burzotta F. Trani C. Romagnoli E. et al. Manual thrombus-aspiration improves myocardial reperfusion: the randomized evaluation of the effect of mechanical reduction of distal embolization by thrombus-aspiration in primary and rescue angioplasty (REMEDIA) trial. J Am Coll Cardiol. 2005; 46: 371-376 Abstract Full Text Full Text PDF PubMed Scopus (327) Google Scholar , 6 Beran G. Lang I. Schreiber W. et al. Intracoronary thrombectomy with the X-sizer catheter system improves epicardial flow and accelerates ST-segment resolution in patients with acute coronary syndrome: a prospective, randomized, controlled study. Circulat. 2002; 105: 2355-2360 Crossref PubMed Scopus (165) Google Scholar ] and it is an easy, quickly performed and cheap adjunct to PCI. However, most previous studies on thrombus aspiration have not been powered for hard clinical endpoints. To date, the only large-scale randomized trial of thrombus aspiration for STEMI to demonstrate a survival benefit is the single-center TAPAS trial in which death was a secondary end point [ 3 Svilaas T. Vlaar P.J. van dH I. et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med. 2008; 358: 557-567 Crossref PubMed Scopus (884) Google Scholar , 7 Vlaar P.J. Svilaas T. van dH I. et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008; 371: 1915-1920 Abstract Full Text Full Text PDF PubMed Scopus (746) Google Scholar ]. In recent guidelines thrombus aspiration has been upgraded to a class IIa recommendation (i.e. it is reasonable to perform the procedure) with a level of evidence: B (i.e. limited populations evaluated) [ [8] Kushner F.G. Hand M. Smith Jr., S.C. et al. Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulat. 2009; 120: 2271-2306 Crossref PubMed Scopus (912) Google Scholar ].