Thrombus aspiration in STEMI: Whom we aspire it may help?

Routine manual thrombus aspiration before percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is a simple, rapid, and inexpensive method to prevent microvascular obstruction (MVO) post PCI [ [1] de Waha S. Patel M.R. Granger C.B. Ohman E.M. Maehara A. Eitel I. Ben-Yehuda O. Jenkins P. Thiele H. Stone G.W. Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: an individual patient data pooled analysis from seven randomized trials. Eur. Heart J. 2017; 38: 3502-3510 Google Scholar ]. Although the TAPAS study initially indicated a clinical benefit for patients who underwent thrombus aspiration before PCI compared to PCI only, later studies and meta-analyses did not show improved clinical outcomes after thrombus aspiration [ 2 Vlaar P.J. Svilaas T. van der Horst I.C. Diercks G.F. Fokkema M.L. de Smet B.J. van den Heuvel A.F. Anthonio R.L. Jessurun G.A. Tan E.S. 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 Google Scholar , 3 Frobert O. Lagerqvist B. Olivecrona G.K. Omerovic E. Gudnason T. Maeng M. Aasa M. Angeras O. Calais F. Danielewicz M. et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N. Engl. J. Med. 2013; 369: 1587-1597 Google Scholar , 4 Lagerqvist B. Frobert O. Olivecrona G.K. Gudnason T. Maeng M. Alstrom P. Andersson J. Calais F. Carlsson J. Collste O. et al. Outcomes 1 year after thrombus aspiration for myocardial infarction. N. Engl. J. Med. 2014; 371: 1111-1120 Google Scholar ]. Beside the absence of clinical benefit, safety issues have been also raised, as patients who underwent thrombus aspiration had higher stroke risk compared to PCI only patients both at 1 month and at 1 year [ [5] Jolly S.S. Cairns J.A. Lavi S. Cantor W.J. Bernat I. Cheema A.N. Moreno R. Kedev S. Stankovic G. Rao S.V. et al. Thrombus aspiration in patients with high Thrombus burden in the TOTAL trial. J. Am. Coll. Cardiol. 2018; 72: 1589-1596 Google Scholar ]. These results have been reflected in the 2023 European Society of Cardiology guidelines for the management of acute coronary syndromes, which discourage the routine use of thrombus aspiration (class III/level of evidence A). However, in certain STEMI patients such as patients with high thrombotic burden after PCI, the guidelines suggest that thrombus aspiration may be considered [ [6] Byrne R.A. Rossello X. Coughlan J.J. Barbato E. Berry C. Chieffo A. Claeys M.J. Dan G.A. Dweck M.R. Galbraith M. et al. 2023 ESC guidelines for the management of acute coronary syndromes. Eur. Heart J. 2023; 44: 3720-3826 Google Scholar ].