Aspiration thrombectomy with primary PCI for STEMI: review of the data and current guidelines

The presence of visible thrombus at the time of primary PCI for STEMI is associated with poor procedural and clinical outcomes. Aspiration thrombectomy has been used with primary PCI in an attempt to improve these outcomes. The TAPAS (Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction) Trial found that aspiration improved myocardial blush scores and ST-segment resolution (STR), and also was associated with lower mortality at 1 year. Four meta-analyses have shown improved measures of myocardial reperfusion (TIMI flow, myocardial blush, and STR) and improved procedural outcomes (reduced no-reflow and distal embolization), and three of four trials have shown reduced mortality. Aspiration thrombectomy has received a Class IIa indication with primary PCI in the recent ACC/AHA and ESC Guidelines. Unanswered questions include whether there is truly a mortality benefit with aspiration, which subgroups may and may not benefit from aspiration, and whether patients with large thrombus burden are better treated with mechanical thrombectomy.