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  • Review Article
  • Published:

Thrombus aspiration in acute myocardial infarction

Nature Reviews Cardiology volume 13, pages 418–428 (2016)Cite this article

Subjects

Key Points

  • Patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) often have distal embolization and microvascular obstruction and, therefore, experience incomplete microvascular myocardial reperfusion, which jeopardizes clinical outcome

  • Manual thrombus aspiration during PCI might limit distal embolization and microvascular obstruction, reduces the need for potentially harmful predilatations, and facilitates direct stenting

  • Although studies have generally demonstrated superior myocardial reperfusion with routine manual thrombus aspiration, no reduction in hard clinical end points was seen when compared with conventional PCI in large clinical trials

  • Safety concerns were raised by a large thrombus aspiration trial that demonstrated a small, but significant, increase in risk of stroke with thrombus aspiration; operator-dependence might have a role

  • Thrombus aspiration has enabled us to study coronary thrombus in vivo, potentially leading to new biomarkers and therapies, and has facilitated recognition of distinct mechanisms of coronary thrombosis

  • A planned meta-analysis of individual patient data will shed more light on the efficacy and safety of thrombus aspiration in primary PCI; selected use by a skilled operator is reasonable while we await the findings

Abstract

The success of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is often hampered by incomplete microvascular myocardial reperfusion owing to distal embolization of thrombus resulting in microvascular obstruction. To address this problem, thrombus aspiration devices have been developed that can be used to evacuate coronary thrombus either manually or mechanically. Thrombus aspiration has the potential to reduce the local thrombus load, minimize the need for balloon predilatation, facilitate direct stenting, prevent distal embolization, and ultimately improve myocardial reperfusion. Furthermore, thrombus aspiration has enabled us to study coronary thrombus in vivo, and has facilitated recognition of distinct mechanisms of coronary thrombosis. Clinical trials focusing on manual thrombus aspiration in primary PCI have generally shown improved myocardial reperfusion. However, in two large trials powered for clinical end points, no reduction in 1-year mortality or other adverse clinical events was observed with the use of this strategy. Moreover, one of these trials showed a marginally increased risk of stroke. Consequently, current guidelines do not recommend routine use of thrombus aspiration. Future studies should focus on the identification of subgroups of patients with STEMI who might derive benefit from manual thrombus aspiration, and establish the effect of operator performance on the efficacy and safety of the procedure.

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Figure 1: Manual thrombus aspiration.
Figure 2: A typical clinical case involving thrombus aspiration in primary percutaneous coronary intervention.
Figure 3: Sizes of the randomized clinical trials in which manual thrombus aspiration was compared with conventional percutaneous coronary intervention.
Figure 4: Thrombi retrieved during thrombus aspiration come in different sizes, shapes, colours, and consistencies.

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Acknowledgements

The authors thank Anouchska S. A. Autar and Heleen M. M. van Beusekom (Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands) for their assistance with Figure 4.

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Authors and Affiliations

  1. Department of Cardiology, Thorax Center, Erasmus Medical Center, 's-Gravendijkwal 230, PO Box 2040, Rotterdam, 3000CA, Netherlands

    Karim D. Mahmoud & Felix Zijlstra

  2. Department of Internal Medicine, Meander Medical Center, Postbus 1502, Amersfoort, 3800 BM, Netherlands

    Karim D. Mahmoud

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Both authors researched data for the article and discussed its content. K.D.M. wrote the manuscript, and F.Z. reviewed and edited it before submission.

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Correspondence to Karim D. Mahmoud.

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Mahmoud, K., Zijlstra, F. Thrombus aspiration in acute myocardial infarction. Nat Rev Cardiol 13, 418–428 (2016). https://doi.org/10.1038/nrcardio.2016.38

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