Stroke in the TOTAL trial: a randomized trial of routine thrombectomy vs. percutaneous coronary intervention alone in ST elevation myocardial infarction

Abstract

Thrombectomy was associated with a significant increase in stroke. Based on these findings, future trials must carefully collect stroke to determine safety in addition to efficacy.

2018 ESC/EACTS Guidelines on myocardial revascularization

“…[223][224][225][226] A safety concern emerged in TOTAL (Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI) trial with an increase in the risk of stroke. 225,227 Taken together, these results suggest that the routine use of thrombus aspiration is not indicated. In the high-thrombus burden subgroup, the trend towards reduced cardiovascular death and increased stroke/transient ischaemic attack (TIA) provides a rationale for future trials of improved thrombus aspiration technologies in this high-risk subgroup (although statistical tests did not support significant subgroup interaction).…”

Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1-year follow-up of the prospective randomised TOTAL trial

“…9,27 A previously published detailed analysis of the strokes in the TOTAL trial showed a significant increase in strokes-mainly ischaemic-in the first 48 h. 27 A potential mechanism of stroke related to thrombectomy is embolisation of thrombus to systemic circulation during removal of the thrombectomy catheter. A landmark analysis showed no difference in late strokes beyond 180 days.…”

ST elevation myocardial infarction

“…24,25 Concerns over increased stent thrombosis rates with drugeluting stent use have not materialised, with newer generation drug-eluting stents being shown to be both safer and more efficacious than bare metal stents in the PPCI setting. 26 Finally, the debate over treatment of non-culprit 'bystander' lesions continues: 30-50% of STEMI patients have significant multivessel disease 27 and current guidelines advocate revascularisation of non-culprit lesions during the index PPCI procedure only in patients who are haemodynamically unstable, or have ongoing ischaemia despite successful culprit vessel PPCI.…”