Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty: An Updated Meta-Analysis of Randomized Trials
What are the clinical outcomes with thrombectomy prior to primary percutaneous coronary intervention (PPCI) compared with conventional PPCI alone?
Clinical trials that randomized acute myocardial infarction (AMI) patients to aspiration or mechanical thrombectomy prior to PPCI compared with conventional PPCI alone were included. For all clinical outcomes, an intention-to-treat analysis was utilized. Summary relative risks (RRs) and their corresponding 95% confidence intervals (CIs) were computed for each dichotomous outcome using fixed and random effects (DerSimonian and Laird method) models.
The weighted mean duration of clinical follow-up was 6 months. Aspiration thrombectomy vs. conventional PPCI (18 trials, n = 3,936): Major adverse cardiac events (MACE) (risk ratio [RR], 0.76; 95% confidence interval [CI], 0.63-0.92; p = 0.006) and all-cause mortality (RR, 0.71; 95% CI, 0.51-0.99; p = 0.049) were significantly reduced with aspiration thrombectomy. Beneficial trends were noted for MI (p = 0.11) and target vessel revascularization (p = 0.06). Final infarct size (p = 0.64) and ejection fraction (p = 0.32) at 1 month were similar. ST-segment resolution (STR) at 60 minutes (RR, 1.31; 95% CI, 1.16-1.48; p < 0.0001) and TIMI blush grade (TBG) 3 post-procedure (RR, 1.37; 95% CI, 1.19-1.59; p < 0.0001) were both improved with aspiration thrombectomy. Mechanical thrombectomy vs. conventional PPCI (seven trials, n = 1,598): There was no difference between the thrombectomy and conventional PPCI arms in the incidence of MACE (RR, 1.10; 95% CI, 0.59-2.05; p = 0.77), mortality (p = 0.57), MI (p = 0.32), target vessel revascularization (p = 0.19), or final infarct size (p = 0.47). A benefit in STR at 60 minutes (RR, 1.25; 95% CI, 1.06-1.47; p = 0.007), but not TBG 3 (RR, 1.09; 95% CI, 0.86-1.38; p = 0.48) was noted.
The authors concluded that thrombectomy during AMI by manual catheter aspiration, but not mechanically, is beneficial in reducing MACE.
This meta-analysis indicates that as compared with conventional PPCI alone, aspiration thrombectomy is associated with a significant 24% reduction in MACE events, including a 29% reduction in all-cause mortality at 6-month median follow-up. On the other hand, mechanical thrombectomy had a neutral effect on clinical outcomes as compared with conventional PPCI alone, with a trend toward a higher incidence of stroke in all trials evaluated. The current analysis supports the routine use of aspiration thrombectomy devices as adjunctive therapy in ST-segment elevation MI (STEMI) patients undergoing PPCI over conventional primary PCI alone, and justifies the Class IIa recommendation for its use in the American College of Cardiology Foundation/American Heart Association STEMI guidelines. Ongoing large multicenter trials (TASTE and TOTAL) comparing aspiration thrombectomy to conventional PPCI will provide additional insight.
Keywords: Myocardial Infarction, Stroke, Suction, Intracellular Signaling Peptides and Proteins, Catheters, Percutaneous Coronary Intervention, omega-Chloroacetophenone, Thrombectomy, India, Parkinson Disease, Coronary Thrombosis, Confidence Intervals, Pregnancy, Prolonged, United States
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