Routine Thrombectomy in Percutaneous Coronary Intervention for Acute ST-Segment–Elevation Myocardial Infarction

Kaltoft, Anne; Bøttcher, Morten; Nielsén, Sören; Hansen, Hans-Henrik Tilsted; Terkelsen, Christian Juhl; Mæng, Michael; Kristensen, Jens; Thuesen, Leif; Krusell, Lars Romer; Kristensen, Steen Dalby; Andersen, Henning; Lassen, Jens Flensted; Rasmussen, Klaus; Rehling, Michael; Nielsen, Torsten T.; Bøtker, Hans Erik

doi:10.1161/circulationaha.105.595660

Cited by 234 publications

(187 citation statements)

References 43 publications

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“…Various thrombectomy devices have been developed allowing manual or mechanical removal of intracoronary thrombi. All thrombectomy devices have shown benefits compared with conventional PPCI, when surrogate endpoints, such as angiographic flow assessment, LVEF assessment, infarct size reduction by perfusion imaging, enzymatic analysis and ST-segment resolution were used [26,29,[73][74][75][76][77][78][79] . To date evidences about hard endpoints from randomized controlled trials, comparing manual and mechanical thrombectomy, are limited and even conflicting.…”

Section: Thrombectomy Devicesmentioning

confidence: 99%

Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

Vecchio¹

2014

WJC

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Acute ST-elevation myocardial infarction (STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator, which is mostly proportional to their size and composition. Particularly, intracoronary thrombi impair both epicardial blood flow and myocardial perfusion, by occluding major coronary arteries and causing distal embolization, respectively. Thus, although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting, the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients, by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used in the setting of STEMI to manage thrombotic lesions.© 2014 Baishideng Publishing Group Inc. All rights reserved. Key words: ST-elevation myocardial infarction; Intracoronary thrombosis; Primary percutaneous coronary intervention; Antithrombotic therapies; Coronary thrombectomyCore tip: Intracoronary thrombosis, is the basic pathophysiologic event in acute ST-elevation myocardial infarction (STEMI), and thrombi are very frequently detected in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). Thrombus burden and components are important determinants of prognosis in STEMI, being well-known risk factors for longterm adverse cardiovascular events, distal embolization and stent thrombosis. As a result, percutaneous management of lesions with a consistent thrombotic burden is still challenging in the setting of PPCI for STEMI. Therefore, several pharmacological and interventional strategies, such as thrombectomy have been developed in order to improve PPCI's safety and efficacy, by reducing thrombus burden.

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Section: Thrombectomy Devicesmentioning

confidence: 99%

Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

Vecchio¹

2014

WJC

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“…In this regard, the use of a mechanical device for thrombus removal or trapping to improve clinical outcomes after p-PCI is attractive, and the efficacy of these devices has been tested in many clinical trials. Although some data, especially those regarding the use of distal protection devices, have failed to show clinical benefits due in part to patient and device selection [48][49][50][51][52][53] , many recent large-scale randomized trials have demonstrated significant improvements in myocardial perfusion 45,[54][55][56][57][58][59][60][61][62][63][64][65][66][67] and the left ventricular function 64,65) in addition to reduced mortality 68) ( 69) . In addition, Burzotta et 70) .…”

Section: Thrombus Aspiration/distal Protection Therapy and Its Efficacymentioning

confidence: 99%

Thrombus Aspiration Therapy and Coronary Thrombus Components in Patients with Acute ST-Elevation Myocardial Infarction

Yunoki

Naruko

Sugioka

et al. 2013

JAT

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Inflammation and oxidative stress play key roles in atherosclerotic plaque instability, and plaque rupture/erosion and subsequent thrombus formation constitute the principal mechanisms of total vessel occlusion and acute ST-elevation myocardial infarction (STEMI). Plaque disruption triggers the formation of initial platelet aggregates that grow in association with an increase in fibrin formation, leading to persistent coronary flow obstruction and blood coagulation. The fibrin network may trap large numbers of erythrocytes and inflammatory cells to form an erythrocyte-rich thrombus. In fact, previous clinical studies have shown that not only platelet-rich white thrombi, but also erythrocyte-rich red thrombi can be visualized using angioscopy in patients with acute coronary syndrome. Recently, the development of thrombus aspiration and distal protection devices has significantly improved the clinical outcomes of percutaneous intervention in STEMI patients and has enabled the evaluation of antemortem coronary artery thrombi. This is important because previous autopsy studies were unable to differentiate coronary thrombi responsible for myocardial ischemia from postmortem clots. Using frozen samples of aspirated thrombi and specific monoclonal antibodies, we investigated the cellular components of thrombi (platelets, erythrocytes, fibrin and inflammatory cells, such as myeloperoxidase-positive cells) and pathologically evaluated the relationships between erythrocyterich thrombi and inflammation, oxidative stress and clinical outcomes in STEMI patients. Therefore, this review article focuses on the efficacy of thrombus aspiration therapy and the components of aspirated intracoronary thrombi in STEMI patients and presents the results of recent studies regarding the relationship between the composition of aspirated intracoronary thrombi and clinical outcomes.

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“…[59][60][61] However, it is not clear whether these benefits also lead to smaller infarcts or better clinical outcomes. [62][63][64] Distal embolic protection failed to show improved microvascular flow, greater reperfusion success, reduced infarct size or enhanced event-free survival. 65,66 Prevention and treatment of susceptibility of microcirculation to injury Individual susceptibility of the microcirculation to ischaemia-reperfusion injury is determined by genetic factors, 67 although acquired risk factors (such as diabetes 68 and hypercholesterolaemia 69 ) may modulate its occurrence.…”

Section: Prevention and Treatment Of Distal Embolizationmentioning

confidence: 99%

Pharmacological and physical prevention and treatment of no-reflow after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction

Guo

Sheng²,

Xu³

et al. 2013

J Int Med Res

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After successful primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, adequate myocardial reperfusion is not achieved in up to 50% of patients. This phenomenon of no-reflow is associated with a poor in-hospital and long-term prognosis. Four main factors are thought to contribute to the occurrence of no-reflow: ischaemic injury; reperfusion injury; distal embolization; susceptibility of the microcirculation to injury. This review evaluates the literature, and in particular the clinical trials, concerned with pharmacological and physical methods for prevention and treatment of no-reflow. A number of drugs may improve no-reflow experimentally and clinically, but some have not yet been associated with conclusive improvements in clinical outcome. The complex interacting factors in no-reflow make it unlikely that any single agent will be effective for all patients. Confirmed methods known to be beneficial in the prevention of no-reflow (such as aspirin therapy, chronic statin therapy, blood glucose control, thrombus aspiration in patients with a high thrombus burden and ischaemic preconditioning) should be offered to patients as often as possible, to prevent and treat no-reflow.

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Routine Thrombectomy in Percutaneous Coronary Intervention for Acute ST-Segment–Elevation Myocardial Infarction

Cited by 234 publications

References 43 publications

Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

Thrombus Aspiration Therapy and Coronary Thrombus Components in Patients with Acute ST-Elevation Myocardial Infarction

Pharmacological and physical prevention and treatment of no-reflow after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction

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