Aspiration Thrombectomy: No Benefit in Large Meta-analysis, Although Selective Use Persists

A large meta-analysis confirms there is no clinical benefit with routine aspiration thrombectomy in primary PCI and points to a possible increase in the risk of stroke.

Those findings echo those of the large TOTAL trial, published last year. Shortly thereafter, the American College of Cardiology and American Heart Association updated their guidelines to state that routine aspiration thrombectomy during primary PCI is not recommended, demoting it to a class III recommendation indicating no benefit.

That’s not to say that interventionalists have forgone use of thrombectomy altogether, according to Dharam Kumbhani, MD (UT Southwestern Medical Center, Dallas, TX), who was not involved in the meta-analysis. “People are still doing it, but they are using it much more selectively,” he told TCTMD, adding that patients with a high thrombus burden are more likely to undergo thrombectomy.

For the meta-analysis, recently published online in the American Journal of Cardiology, Mark Eisenberg, MD (Jewish General Hospital/McGill University, Montreal, Canada), and colleagues looked at 18 contemporary studies that compared routine aspiration thrombectomy with primary PCI alone in more than 20,000 STEMI patients with follow-up of at least 6 months. While its use was associated with higher likelihood of ST-segment resolution (RR 1.22; 95% CI 1.07-1.40) and myocardial blush grade 3 (RR 1.30; 95% CI 1.01-1.67) and a lower risk of no reflow immediately post-PCI (RR 0.63; 95% CI 0.40-0.98), thrombectomy was not linked with improvements in clinical endpoints including mortality. In fact, it appeared to increase the risk of stroke.

These findings suggest “that the clinical efficacy of routine aspiration thrombectomy during primary PCI has previously been overestimated,” the researchers write, adding that data from TOTAL and TASTE have “nuanced the evidence base supporting routine” use of it.

According to Kumbhani, the results of the meta-analysis are unlikely to sway practice beyond any changes already made in response to the clinical trial results and guidance document. “What they found [for the] most part has been reported before,” he said, adding that he would only alter his practice if thrombectomy actually improved hard outcomes.

While another large randomized trial of routine thrombectomy is unlikely, Kumbhani said he would like to see more research on its selective use. “This may end up being one of those devices that we use only when needed, . . . but you are using it more because you want to do a better job of fixing the blood vessel [than improve mortality],” he noted.

STEMI patients who present “really late” could be good candidates and thus “might be a population to study,” as might patients who have very high thrombus burdens, Kumbhani suggested. “There are thrombus grading systems so you can actually quantify the amount of clot that you have built up inside the blood vessel at the time of angioplasty, and if you had higher grades I suppose you could study that population.”

Related Stories:

• Two New Studies Strengthen Case Against Thrombus Aspiration in STEMI
• Guideline Update Boosts Nonculprit PCI, Knocks Down Aspiration Thrombectomy
• TOTAL: Use of Routine Thrombectomy in Primary PCI Takes Another Blow