Present Role of Thrombectomy in STEMI Interventions

The major challenge in the treatment of ST-elevation myocardial infarction (STEMI) is not only restoration of normal coronary blood flow but also microvascular perfusion. Although primary percutaneous coronary intervention (pPCI) has contributed to a dramatic reduction in cardiovascular mortality over three decades, normal myocardial perfusion is not restored in approximately one-third of these patients and distal embolization of the thrombus and plaque fragments seem to be the main causes of myocardial reperfusion failure. Initial enthusiasm for manual thrombectomy arose after the apparent mortality benefit observed in the single-centre randomized TAPAS trial (1,071 patients), with consequent upgrading of thrombus aspiration in the STEMI revascularization guidelines. However, the TAPAS trial was considerably challenged by the TASTE trial (7,244 patients) and recently by the TOTAL trial (10,732). These two prospective and multicenter studies were negative with regard to both their primary endpoints as well as their major secondary endpoints except for stroke rates in TOTAL which were slightly increased in the thrombus aspiration group, and possibly due to chance. With the published results of the TOTAL and TASTE trials it seems certain that there is no clinical benefit of routine thrombus aspiration in patients with STEMI during PCI. However, criticism has been raised that both trials have included a lower-risk population. Thus, there is still some uncertainty regarding the benefit for high-risk patients.