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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!
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