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Tips and tricks for thrombus aspiration in STEMI Dinh Duc Huy, MD, FSCAI Tam Duc Heart Hospital STEMI PPCI is complex! Some issues of thrombus aspiration • Thrombus presence is associated with adverse clinical outcomes • Thrombus aspiration can be performed successfully in most patients with acute STEMI; often leads to better reperfusion • Potential complications include distal embolization, endothelial damage from forceful aspiration and trauma to tortuous proximal vessels from the aspiration device • Data have changed from TAPAS (2008) … to TASTE (2013) & TOTAL (2015) • • • • Single center, prospective, randomized 1,071 patients with STEMI Randomized 1:1 before angiography Primary endpoint – Myocardial blush grade (core lab) • Secondary endpoints – ST-segment elevation resolution – 30 day death and death/ reinfarction – 1-year death and death/ reinfarction N Engl J Med 2008;358:557-67 TAPAS- year clinical outcomes Thrombus aspiration results in a lower mortality and combined mortality/non-fatal reinfarction 12 Conventional PCI Thrombus-Aspiration Mortality (%) 10 Log-Rank p = 0.040 Death or Reinfarction (%) 12 Conventional PCI Thrombus-Aspiration 10 Log-Rank p = 0.016 0 100 200 300 400 100 300 Time (days) Time (days) Mortality 200 Death or Re-infarction N Engl J Med 2008;358:557-67 400 • 7244 patients with STEMI TASTE TAPAS JETSTENT AIMI • 3621 manual thrombus aspiration followed by PCI INFUSE-AMI VAMPIRE PREPARE Chevalier Kaltoft • 3623 PCI only MUSTELA X AMINE ST PIHRATE • The primary end point was all-cause mortality at 30 days N Engl J Med 2013;369:1587-97 EXPIRA DEAR-MI Liistro 1000 2000 3000 4000 5000 6000 Number of patients TASTE and previous studies 7000 8000 TASTE results at 30 days No benefit of manual thrombus aspiration as a routine adjunct to PCI in STEMI HR 0.94 (0.72 - 1.22), P=0.63 Mortality N Engl J Med 2013;369:1587-97 HR 0.61 (0.34 - 1.07), P=0.09 Re-infarction The TOTAL Trial Study Design STEMI* with Primary PCI ≤12 hours of symptom onset Sample size of 10,700 for 80% power to detect a 20% Relative Risk Reduction 1:1 Randomization between strategies Routine Upfront Manual Thrombectomy followed by PCI PCI Alone (only bailout thrombectomy) Primary Outcome: CV death, MI, cardiogenic shock and class IV heart failure ≤180 days Safety Outcome: Stroke ≤30 days • Bailout Thrombectomy allowed if PCI alone strategy fails: Persistent TIMI or flow with large thrombus after balloon pre-dilatation • Persistent large thrombus after stent deployment at target lesion Jolly SS N Engl J Med 2015;372:1389-98 TOTAL Primary outcomes & safety outcomes Day 180 Thrombectomy (N=5033) (%) PCI alone (N=5030) (%) HR 95% CI p 347 (6.9%) 351 (7.0%) 0.99 0.85-1.15 0.86 CV death 157 (3.1%) 174 (3.5%) 0.90 0.73-1.12 0.34 Recurrent MI 99 (2.0%) 92 (1.8%) 1.07 0.81-1.43 0.62 Cardiogenic Shock 92 (1.8%) 100 (2.0%) 0.92 0.69-1.22 0.56 Class IV CHF 98 (1.9%) 90 (1.8%) 1.09 0.82-1.45 0.57 CV death, MI, shock or class IV heart failure Stroke within 30 days 33 (0.7%) 16 (0.3%) 2.06 1.13-3.75 0.015 Stroke or TIA within 30 days 42 (0.8%) 19 (0.4%) 2.21 1.29-3.80 0.003 Stroke within 180 days 52 (1.0%) 25 (0.5%) 2.08 1.29-3.35 0.002 2015 ACC/AHA/SCAI Focused Update on Primary PCI A suggested clinical algorithm during primary PCI Dharma S, Kedev S, Jukema JW Heart 2013;99:279-284 Things to be prepared for thrombus aspiration • • • • • • Data- Level of evidence Thrombus burden (large, small, none) Which aspiration devices to be used? Size Fr or Fr.? Distal protection? How many runs? Different devices Different profiles Manual versus Non-manual Gu YL, Zijlstra F In: Oxford Textbook of Interventional Cardiology, 2010 Tips for thrombus aspiration  Selection of guide, Fr system in the small/mid size vessel, Fr in the large vessel Good guide support is important  Gentle advancing the catheter (can easily kink)  Keep guide deeply engaged may help to avoid systemic embolization  Start aspiration cm before the lesion with the thrombus, move the catheter forward very slowly and pass the lesion with continuous aspiration Tips for thrombus aspiration (cont.)  Remove the catheter with aspiration even into the guide catheter, aspirate the blood from the guide catheter  Remove the catheter outside slowly if a large thrombus is caught on the tip of catheter and completely block the aspiration  Multiple attempts (according to angiographic result)  Fr ST01 “Child” catheter in 6Fr./ 7Fr “ Mother” Guide may help to aspirate big and old thrombus in late presented AMI Thank you for your attention!