Operator Variation in Aspiration Thrombectomy

Study Questions:

What are the temporal trends and comparative outcomes of aspiration thrombectomy (AT) during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI)?

Methods:

The investigators conducted a retrospective cohort study of the National Cardiovascular Data Registry (NCDR) CathPCI Registry from July 1, 2009, to June 30, 2016, to assess temporal trends and in-hospital outcomes associated with AT use. To evaluate outcomes through 180 days, a subanalysis was conducted among Centers for Medicare and Medicaid Services–linked patients from July 1, 2009, through December 31, 2014. The comparative effectiveness analysis was performed using instrumental variable analyses to account for treatment selection bias. The instrumental variable was operator’s preference to use AT during pPCI. Data were analyzed between February 1, 2017, and April 1, 2018. Primary outcomes included in-hospital stroke and death. Secondary outcomes included heart failure, stroke, all-cause rehospitalization, and death through 180 days of follow-up.

Results:

Among all pPCIs performed (683,584), the mean (standard deviation) age of patients was 61.7 (12.8) years, 489,257 were male (71.6%), and 596,384 were white (87.2%). Among patients undergoing pPCI, AT use increased from 2009 through 2011, with peak use of 13.8%. This was followed by a decline of >9%, reaching 4.7% by mid-2016. Overall, AT was used in 10.8% of pPCIs (lowest operator group median, 0%; highest operator group median, 33.8%). After instrumental variable analysis, AT use was associated with no difference in in-hospital death (adjusted absolute risk difference, −0.18%; 95% confidence interval [CI], −0.53% to 0.16%; p = 0.29) and a small increase in in-hospital stroke (adjusted risk difference, 0.14%; 95% CI, 0.01%-0.30%; p = 0.03). Among Centers for Medicare and Medicaid Services–linked patients, AT use was not associated with differences in death, heart failure, stroke, or rehospitalization at 180 days.

Conclusions:

The authors concluded that while AT use during STEMI pPCI declined by >50% since 2011, selective AT use was associated with a small excess risk of in-hospital stroke and no difference in other outcomes through 180 days of follow-up.

Perspective:

This nationwide analysis of patients undergoing pPCI for STEMI reports that AT use is appropriately declining nationwide, corresponding with evolving negative trial data. Furthermore, there was no clinical benefit of selective AT use during pPCI for STEMI and should be discouraged. Of note, despite declining population-level trends, operator preferences for AT varied substantially, with some operators choosing never to use AT during STEMI pPCI and other operators using AT in >20% of cases, and could be the focus of quality improvement initiatives, particularly given its association with a small increase in the risk of in-hospital stroke.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS

Keywords: Acute Coronary Syndrome, CathPCI Registry, Centers for Medicare and Medicaid Services (U.S.), Heart Failure, Hospital Mortality, Myocardial Infarction, Percutaneous Coronary Intervention, Primary Prevention, Quality Improvement, Stroke, Thrombectomy


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