Aspiration thrombectomy fails to demonstrate benefit in primary PCI  

Although primary percutaneous coronary intervention (PPCI) restores epicardial coronary flow in the majority of patients with ST-segment myocardial infarction, this approach can lead to microvascular obstruction resulting from distal embolization of thrombus.  Manual thrombectomy (i.e. aspiration thrombectomy) prior to PPCI has been proposed as a method to reduce thrombus burden and resultant distal embolization with PPCI.  Although results from early studies of aspiration thrombectomy suggested improvements in patient outcomes, subsequent trials have failed to demonstrate a clinical benefit of aspiration thrombectomy prior to PPCI.  This large, multi-centre, international trial furthers the evidence that aspiration does not offer benefit in the routine care of patients undergoing PPCI.  This study randomized 10,732 patients with ST elevation myocardial infarction to routine manual thrombectomy prior to PCI or standard PCI alone.  The primary outcome was a composite of death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days with a primary safety end-point of stroke within 30 days.  Crossover rates between groups were low and the primary analysis was by intention-to-treat.  Compared to standard PPCI, treatment with aspiration thrombectomy did not reduce rates of the primary outcome (6.9% vs. 7.0%, HR, 0.99; 95% CI, 0.85 to 1.15; P=0.86) or individual components of the primary outcome.  In a pre-specified sub-group analysis, there was no difference in patient outcomes as a function of initial thrombus burden. Furthermore, there was a significant increase in stroke in the thrombectomy group (0.7% vs. 0.3%, HR, 2.06; 95% CI, 1.13 to 3.75; P=0.02) within the first 30 days. 

Conclusions: In this large randomised controlled trial, routine aspiration thrombectomy did not improve patient outcomes for patients presenting with acute ST-elevation myocardial infarction.  Rates of stroke in patients undergoing thrombectomy were significantly elevated at 30 days.  Aspiration thrombectomy should no longer be a part of routine PCI care.

 

Summarized by Hussain Contractor and Steven M. Bradley

 

  • Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ, Kedev S, Thabane L, Stankovic G, Moreno R, Gershlick A, Chowdhary S, Lavi S, Niemelä K, Steg PG, Bernat I, Xu Y, Cantor WJ, Overgaard CB, Naber CK, Cheema AN, Welsh RC, Bertrand OF, Avezum A, Bhindi R, Pancholy S, Rao SV, Natarajan MK, Ten Berg JM, Shestakovska O, Gao P, Widimsky P and Džavík V.  Randomized Trial of Primary PCI with or without Routine Manual Thrombectomy.  N Engl J Med. 2015 Mar 16. [Epub ahead of print]