Long‐term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta‐analysis of randomized trials

Akram Y Elgendy; Islam Y Elgendy; Ahmed N Mahmoud; Anthony A Bavry

doi:10.1002/clc.22691

. 2017 Apr 13;40(8):534–541. doi: 10.1002/clc.22691

Long‐term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta‐analysis of randomized trials

Akram Y Elgendy ¹, Islam Y Elgendy ², Ahmed N Mahmoud ², Anthony A Bavry ^2,^3,^✉

PMCID: PMC6490371 PMID: 28409835

Abstract

Randomized clinical trials that examined long‐term clinical outcomes of routine aspiration thrombectomy prior to primary percutaneous coronary intervention (PCI) in patients with acute ST‐segment elevation myocardial infarction have yielded different results. We hypothesized that the routine use of manual thrombus aspiration prior to primary PCI lacks long‐term clinical benefits. Electronic databases were searched for randomized trials comparing routine aspiration thrombectomy and conventional PCI. We included only trials that reported clinical outcomes beyond 6 months. The primary outcome was all‐cause mortality, and the secondary outcomes included major adverse cardiovascular events, re‐infarction, cardiovascular mortality, and stent thrombosis (ST). A DerSimonian‐Laird model was used to construct the summary estimates risk ratio (RR). We retrieved 18 trials with 20 641 ST‐segment elevation myocardial infarction patients, of whom 10 331 patients underwent routine aspiration thrombectomy prior to primary PCI. At a mean follow‐up of 12 months, there was no significant decrease in the risk of all‐cause mortality (RR: 0.93, 95% confidence interval [CI]: 0.82‐1.05, P = 0.22), major adverse cardiac events (RR: 0.95, 95% CI: 0.87‐1.03, P = 0.18), re‐infarction (RR: 0.95, 95% CI: 0.80‐1.13, P = 0.59), cardiovascular mortality (RR: 0.80, 95% CI: 0.47‐1.36, P = 0.40), or ST (RR: 0.80, 95% CI: 0.63‐1.01, P = 0.06) with routine aspiration thrombectomy. Routine aspiration thrombectomy prior to primary PCI was not associated with a reduction in long‐term mortality or clinical outcomes. Future randomized trials are warranted to further evaluate the role of aspiration thrombectomy in select patients and coronary lesions.

Keywords: aspiration thrombectomy, percutaneous coronary intervention, Ischemic heart disease, myocardial infarction, meta‐analysis, mortality

INTRODUCTION

Despite the advances in the treatment of ST‐segment elevation myocardial infarction (STEMI), the mortality remains considerably high.1, 2, 3 Primary percutaneous coronary intervention (PCI) remains the cornerstone of treatment because it is associated with a significant reduction in morbidity and mortality by the restoration of epicardial blood flow; however, there is a risk of distal embolization and microvascular occlusion after stent placement or balloon dilatation in a phenomenon known as “no‐reflow phenomenon,” which is associated with worse outcomes. Hence, aspiration thrombectomy was designed as an adjunctive tool to aid in the restoration of the coronary blood flow.4, 5, 6 Earlier meta‐analysis had suggested that routine use of manual thrombus aspiration was associated with better clinical outcomes.7 However, more recent randomized clinical trials (RCTs) and meta‐analyses showed that the routine use of aspiration thrombectomy in STEMI was not associated with any benefit on short‐term outcomes.8, 9, 10 Those studies raised a question regarding the safety of routine aspiration thrombectomy prior to primary PCI, due to a potential increased risk of stroke.10, 11, 12 As a result, the updated American College of Cardiology/American Heart Association (ACC/AHA) guidelines no longer endorse routine aspiration thrombectomy prior to primary PCI and recommend its use only in select patients.2 A meta‐analysis of randomized trials had previously suggested that aspiration thrombectomy might impact intermediate‐term outcomes (ie, 6–12 months).13 Given that additional trials evaluating the long‐term outcomes of aspiration thrombectomy have become available,11, 12, 13, 14, 15, 16, 17, 18 we sought to conduct an updated comprehensive meta‐analysis of randomized trials to evaluate the impact of aspiration thrombectomy on long‐term clinical outcomes (ie, beyond 6 months).

METHODS

Data sources

We performed a computerized database search of the Medline, Cochrane Library, and Web of Science databases from inception until January 2017 without language restriction. To construct our search strategy, we used the following medical subject headings terms and keywords: “thrombectomy,” “thrombus aspiration,” “thromboaspiration,” and “myocardial infarction.” Furthermore, we reviewed the previously published meta‐analyses and the references of published trials to ensure no missing trials. Figure 1 illustrates the search strategy. The current meta‐analysis was registered at the International Prospective Register for Systematic Reviews (PROSPERO) as CRD42015019199.

Search strategy conducted for all the included trials. Abbreviations: MeSH, medical subject headings.

Selection criteria and data extraction

Published RCTs that reported clinical outcomes with routine aspiration thrombectomy prior to primary PCI vs routine conventional primary PCI in STEMI patients within 12 hours of symptoms’ onset were included. We included all trials that reported clinical outcomes ≥6 months. For the trials that reported variable follow‐up duration, we utilized the longest available follow‐up duration. We excluded (1) trials that only reported clinical outcomes <6 months, (2) trials that enrolled patients with delayed STEMI presentation >12 hours, and (3) trials that enrolled patients with rescue PCI. Data regarding sample size, patient demographics, trial design, and clinical outcomes of interest from the included trials were retrieved by 2 independent investigators. Consensus was resolved among the authors.

Quality assessment of the trials included

We used the Cochrane Collaboration's tool for assessing the risk of bias to assess the quality of the included trials.19 We reviewed the following components: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective data, and other sources of bias. We defined trials with <2 components of bias as trials with low risk of bias (high‐quality trials) and trials with ≥2 components of bias as trials with high risk of bias (low‐quality trials).

Clinical outcomes and definitions

The primary outcome of interest was all‐cause mortality. Secondary outcomes included major adverse cardiovascular events (MACE), re‐infarction, cardiovascular mortality, and stent thrombosis (ST). In this meta‐analysis, we did not focus on the risk of stroke, as this has been previously reported and there are no additional trials exploring this outcome.12 The definition of clinical outcomes of interest was adopted per the individual trials.

Statistical analysis

We conducted this meta‐analysis in concordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.20 We used an intention‐to‐treat analysis to investigate the outcomes of interest. We constructed random effects summary risk ratio (RR) using a DerSimonian‐Laird model.21 We excluded studies that reported zero events in both arms. We assessed the heterogeneity among the studies by calculating the I ² statistic. We considered I ² values <25%, 25% to 50%, and >50% as a low, moderate, and high degree of heterogeneity, respectively.22 Publication bias was assessed with the Egger test.23 For the primary outcome (all‐cause mortality), we performed a subgroup analysis comparing trials that were deemed to be low risk of bias (using the Cochrane tool) vs intermediate/high risk of bias, and another subgroup analysis was performed comparing large trials (ie, including ≥1000 patients) vs small trials (ie, including <1000 patients). All P values were 2‐tailed, and we set the P value at <0.05 for statistical significance. We performed the statistical analysis using STATA software version 14.0 (StataCorp, College Station, TX).

RESULTS

Eighteen trials were retrieved, encompassing 20 641 patients: 10 331 patients underwent routine aspiration thrombectomy prior to primary PCI and 10 310 patients were in the conventional primary PCI arm.8, 11, 14, 15, 16, 17, 18, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 (For a summary of the Cochrane risk‐of‐bias assessment tool and the quality measures for the individual trials, see Supporting Information, Tables 1 and 2, in the online version of this article.) All trials were retrieved from Medline, and the other sources did not identify any further trials. The weighted mean follow‐up was 12 months (range, 6–24 months). The mean patient age was 62 ± 3 years, with 76% ± 9% of patients being male in both groups. The mean ischemic time was similar in both groups (4.2 ± 1.4 hours in the aspiration thrombectomy group vs 4.2 ± 1.6 hours in the conventional primary PCI group).

The Export aspiration catheter (Medtronic Inc, Santa Rosa, CA, USA) was the most common catheter used.11, 14, 16, 17, 24, 25, 26, 27, 30, 31, 33 Other devices used were the Thrombuster II (Kaneka Medical Products, Osaka, Japan) in 3 trials,15, 18, 29 Diver CE (Invatec, Roncadelle, Brescia, Italy) in 2 trials,28, 34 and Nipro (Nipro, Osaka, Japan) in 1 trial.32 For Thrombus Aspiration in ST‐Elevation Myocardial Infarction in Scandinavia (TASTE), the investigators used different catheters according to the local site's preference: Export, Eliminate (Terumo Interventional Systems Europe, Leuven, Belgium), and OXT or Pronto (Vascular Solutions, Minneapolis, MN).8 Table 1 summarizes the baseline characteristics and follow‐up duration of the included trials.

Table 1.

Baseline characteristics of the included trials

Study	Year	Device	AT/No AT	Mean Age, y	Male Sex, %	DM, %	Follow‐up Duration, mo	Mean Ischemic Time, h¹
IMPACT	2015	Export	21/20	65/67	76/75	24/15	6	3/3.4
COCTAIL II	2015	Thrombuster II	64/64	62/63	81/86	14/16	24²	2.9/2.9
TOTAL	2015	Export	5372/5360	61/61	77/78	18/19	12	3/2.9²
TASTE	2014	Export, Eliminate, OXT, or Pronto	3621/3623	67/66	75/75	75/75	12	3.1/3²
Shehata et al	2014	Export	50/50	60/59	62/66	100/100	8	NR
ADMIT	2014	Export	49/51	58/57	90/82	27/45	6	4.1/4.1
INFUSE‐AMI	2013	Export	229/223	61/59	74/74	15/8	12	2.4/2.7²
Sim et al	2013	Thrombuster II	43/43	63/60	67/70	28/33	12	4/3
Bulum et al	2012	Export	30/30	54/59	83/73	10/10	6	4.9/3.9
MUSTELA	2012	Export	50/104	62/63	88/76	19/20	12	3.8/3.5²
PIHRATE	2010	Diver CE	100/96	61/59	80/82	13/10	6	NR/NR
ITTI	2010	Thrombuster II	52/48	61/57	90/82	27/25	6	4.6/4.1
Liistro et al	2009	Export	55/56	64/65	78/77	20/12	6	3.2/3.5
EXPIRA	2009	Export	88/87	67/65	65/55	24/18	24	6.2/6.1
VAMPIRE	2008	Nipro	180/175	63/64	81/78	23/30	8	6.3/7.1
Chao et al	2008	Export	37/37	60/62	84/86	32/22	6	5.2/5.5
TAPAS	2008	Export	535/536	63/63	68/73	11/13	12	3.2/3.1²
De Luca et al	2006	Diver CE	38/38	67/65	71/55	24/18	6	7.3/7.6

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Abbreviations: ADMIT, Aspiration Device Myocardial Infarction Trial; AT, aspiration thrombectomy; COCTAIL II, Randomized Trial of Standard vs ClearWay‐infused Abciximab and Thrombectomy for Myocardial Infarction; DM, diabetes mellitus; EXPIRA, Thrombectomy With Export Catheter in Infarct‐Related Artery During Primary Percutaneous Coronary Intervention; IMPACT, Serial Assessment of the Index of Microcirculatory Resistance During Primary Percutaneous Coronary Intervention Comparing Manual Aspiration Catheter Thrombectomy With Balloon Angioplasty; INFUSE‐AMI, Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction; ITTI, Initial Thrombosuction and Tirofiban Infusion trial; MUSTELA, Multidevice Thrombectomy in Acute ST‐Segment Elevation Acute Myocardial Infarction; NR, not reported; PCI, percutaneous coronary intervention; PIHRATE, Polish‐Italian‐Hungarian Randomized Thrombectomy trial; STEMI, ST‐segment elevation myocardial infarction; TAPAS, Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study; TASTE, Thrombus Aspiration in ST‐Elevation Myocardial Infarction in Scandinavia; TOTAL, Thrombectomy With PCI vs PCI Alone in Patients With STEMI; VAMPIRE, Vacuum Aspiration Thrombus Removal.

Data are reported as AT prior PCI/conventional PCI with no AT.

Ischemic time is defined as time from onset of symptoms until balloon.

Median.

Outcomes

All trials reported all‐cause mortality, except for 3 trials that reported only cardiac death.15, 16, 18 There was no difference in the risk of all‐cause mortality (RR: 0.93, 95% confidence interval [CI]: 0.82‐1.05, P = 0.22, I ² = 0.0%; Figure 2). There was no evidence of publication bias with the Egger test (P = 0.653). Subgroup analysis showed no difference in the risk of all‐cause mortality between the trials that were deemed to be low risk for bias and those deemed to be intermediate/high risk of bias (RR: 0.92, 95% CI: 0.82‐1.05, P = 0.22 vs RR: 0.99, 95% CI: 0.30‐3.32, P = 0.99, respectively; see Supporting Information, Figure 1, in the online version of this article). In addition, subgroup analysis showed no difference between large (ie, ≥1000 patients) trials vs small (ie, <1000 patients) trials (RR: 0.91, 95% CI: 0.76‐1.07, P = 0.25 vs RR: 0.99, 95% CI: 0.61‐1.63, P = 0.98, respectively; see Supporting Information, Figure 2, in the online version of this article).

Summary random effects OR for all‐cause mortality. The relative size of the data markers indicates the weight of the sample size from each study. Abbreviations: ADMIT, Aspiration Device Myocardial Infarction Trial; CI, confidence interval; COCTAIL II, Randomized Trial of Standard vs ClearWay‐infused Abciximab and Thrombectomy for Myocardial Infarction; EXPIRA, Thrombectomy With Export Catheter in Infarct‐Related Artery During Primary Percutaneous Coronary Intervention; IMPACT, Serial Assessment of the Index of Microcirculatory Resistance During Primary Percutaneous Coronary Intervention Comparing Manual Aspiration Catheter Thrombectomy With Balloon Angioplasty; INFUSE‐AMI, Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction; ITTI, Initial Thrombosuction and Tirofiban Infusion trial; MUSTELA, Multidevice Thrombectomy in Acute ST‐Segment Elevation Acute Myocardial Infarction; OR, odds ratio; PCI, percutaneous coronary intervention; PIHRATE, Polish‐Italian‐Hungarian Randomized Thrombectomy trial; RR, risk ratio; STEMI, ST‐segment elevation myocardial infarction; TAPAS, Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study; TASTE, Thrombus Aspiration in ST‐Elevation Myocardial Infarction in Scandinavia; TOTAL, Thrombectomy With PCI vs PCI Alone in Patients With STEMI; VAMPIRE, Vacuum Aspiration Thrombus Removal.

Regarding the secondary outcomes, MACE were reported in 17 trials (all but the Serial Assessment of the Index of Microcirculatory Resistance During Primary Percutaneous Coronary Intervention Comparing Manual Aspiration Catheter Thrombectomy With Balloon Angioplasty [IMPACT] study).14 There was no difference in risk of MACE between the aspiration thrombectomy group and the conventional primary PCI group (RR: 0.95, 95% CI: 0.87‐1.03, P = 0.18, I ² = 0.0%; Figure 3). Table 2 reports the primary outcome and the definition of MACE per the individual trials. For the other clinical outcomes, aspiration thrombectomy was not associated with a reduction in the risk of re‐infarction (RR: 0.95, 95% CI: 0.80‐1.13, P = 0.59, I ² = 0.0%; see Supporting Information, Figure 3, in the online version of this article), cardiovascular mortality (RR: 0.80, 95% CI: 0.47‐1.36, P = 0.40, I ² = 38%; see Supporting Information, Figure 4, in the online version of this article), or ST (RR: 0.80, 95% CI: 0.63‐1.01, P = 0.06, I ² = 0.0%; see Supporting Information, Figure 5, in the online version of this article). There was no evidence of publication bias for all the secondary outcomes except for cardiovascular mortality, with a moderate degree of heterogeneity.

Summary random effects OR for major adverse cardiovascular events. The relative size of the data markers indicates the weight of the sample size from each study. Abbreviations: ADMIT, Aspiration Device Myocardial Infarction Trial; CI, confidence interval; COCTAIL II, Randomized Trial of Standard vs ClearWay‐infused Abciximab and Thrombectomy for Myocardial Infarction; EXPIRA, Thrombectomy With Export Catheter in Infarct‐Related Artery During Primary Percutaneous Coronary Intervention; IMPACT, Serial Assessment of the Index of Microcirculatory Resistance During Primary Percutaneous Coronary Intervention Comparing Manual Aspiration Catheter Thrombectomy With Balloon Angioplasty; INFUSE‐AMI, Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction; ITTI, Initial Thrombosuction and Tirofiban Infusion trial; MUSTELA, Multidevice Thrombectomy in Acute ST‐Segment Elevation Acute Myocardial Infarction; OR, odds ratio; PCI, percutaneous coronary intervention; PIHRATE, Polish‐Italian‐Hungarian Randomized Thrombectomy trial; RR, risk ratio; STEMI, ST‐segment elevation myocardial infarction; TAPAS, Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study; TASTE, Thrombus Aspiration in ST‐Elevation Myocardial Infarction in Scandinavia; TOTAL, Thrombectomy With PCI vs PCI Alone in Patients With STEMI; VAMPIRE, Vacuum Aspiration Thrombus Removal.

Table 2.

Primary outcome and MACE definition per the individual trials

Study	Primary Outcome	MACE Definition
IMPACT	Myocardial reperfusion markers	Death from any cause or MI
COCTAIL II	Residual intrastent atherothrombotic area	Cardiac death, nonfatal MI, or TLR
TOTAL	Composite of cardiac death, recurrent MI, cardiogenic shock, or class IV HF	Cardiac death, recurrent MI, cardiogenic shock or class IV HF, ST, or TVR
TASTE	All‐cause mortality	NR
Shehata et al	In‐stent restenosis	Composite of cardiac death, MI, and TLR
ADMIT	Myocardial reperfusion markers	Death, re‐infarction, and TVR
INFUSE‐AMI	Infarct size by MRI	Death, re‐infarction, stroke, or TVR
Sim et al	Infarct size by MRI	Composite of cardiac death, MI, and TVR
Bulum et al	In‐stent restenosis	Death, re‐infarction, stroke, or TLR
MUSTELA	Myocardial reperfusion markers and infarct size	Composite of death, re‐infarction, and TVR
PIHRATE	Myocardial reperfusion markers	NR
ITTI	Myocardial reperfusion markers	Death, re‐infarction, stroke, and TLR
Liistro et al	Myocardial reperfusion markers	NR
EXPIRA	Myocardial reperfusion markers	Cardiac death, nonfatal MI, TVR
VAMPIRE	Myocardial reperfusion markers	Composite of death, nonfatal MI, and TLR
Chao et al	Myocardial reperfusion markers	Death, nonfatal MI, stroke, and TVR
TAPAS	Myocardial reperfusion markers	NR
De Luca et al	LV remodeling	Death, MI, and HF hospitalization

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Abbreviations: ADMIT, Aspiration Device Myocardial Infarction Trial; COCTAIL II, Randomized Trial of Standard vs ClearWay‐infused Abciximab and Thrombectomy for Myocardial Infarction; EXPIRA, Thrombectomy With Export Catheter in Infarct‐Related Artery During Primary Percutaneous Coronary Intervention; HF, heart failure; IMPACT, Serial Assessment of the Index of Microcirculatory Resistance During Primary Percutaneous Coronary Intervention Comparing Manual Aspiration Catheter Thrombectomy With Balloon Angioplasty; INFUSE‐AMI, Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction; ITTI, Initial Thrombosuction and Tirofiban Infusion trial; LV, left ventricular; MACE, major adverse cardiovascular events; MI, myocardial infarction; MRI, magnetic resonance imaging; MUSTELA, Multidevice Thrombectomy in Acute ST‐Segment Elevation Acute Myocardial Infarction; NR, not reported; PCI, percutaneous coronary intervention; PIHRATE, Polish‐Italian‐Hungarian Randomized Thrombectomy trial; ST, stent thrombosis; STEMI, ST‐segment elevation myocardial infarction; TAPAS, Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study; TASTE, Thrombus Aspiration in ST‐Elevation Myocardial Infarction in Scandinavia; TLR, target‐lesion revascularization; TOTAL, Thrombectomy With PCI vs PCI Alone in Patients With STEMI; TVR, target‐vessel revascularization; VAMPIRE, Vacuum Aspiration Thrombus Removal.

DISCUSSION

In this updated comprehensive meta‐analysis of 18 RCTs with 20 641 patients with STEMI presenting at <12 hours, we examined the long‐term efficacy of routine aspiration thrombectomy prior to primary PCI. At a mean follow‐up of 12 months, we demonstrated that routine aspiration thrombectomy prior to primary PCI has no apparent benefit on clinical endpoints (eg, all‐cause mortality, MACE, re‐infarction, and cardiovascular mortality); however, there was a trend of lower ST with aspiration thrombectomy, which could probably be due to an overestimation of the treatment effect, given the small number of events.

The ACC/AHA had previously endorsed the routine aspiration thrombectomy (class 2a)3 based on limited data from a single‐center trial24 and small multicenter trials that showed that routine aspiration thrombectomy was associated with improvement of both clinical outcomes and surrogates of myocardial perfusion.31, 32 This led to a widespread rise in the routine use of aspiration thrombectomy in STEMI as a relatively simple procedure prior to primary PCI.35 Recently, 2 large multicenter RCTs—Outcomes 1 Year After Thrombus Aspiration for Myocardial Infarction8 and Outcomes After Thrombus Aspiration for ST‐elevation Myocardial Infarction: 1‐Year Follow‐up of the Prospective Randomised TOTAL trial (Thrombectomy With PCI vs PCI Alone in Patients With STEMI)11—were powered for long‐term clinical outcomes, and the investigators demonstrated that there was no difference in the long‐term clinical outcomes with routine aspiration thrombectomy compared with conventional primary PCI. Based on this evidence, the ACC/AHA updated its guidelines to recommend against routine aspiration thrombectomy prior to primary PCI (class 3).2 The current study adds to the body of evidence that supports against routine aspiration thrombectomy, given the lack of benefit in the long term. Although mechanical thrombectomy has been shown to improve the outcomes in acute ischemic stroke via improving recanalization rates,36 routine aspiration thrombectomy appears not to improve clinical outcomes despite improving myocardial reperfusion. One potential reason could be that available aspiration thrombectomy devices could be ineffective.37

Study limitations

Previous meta‐analyses were able to demonstrate long‐term clinical benefits from the routine use of aspiration thrombectomy prior to primary PCI13, 38; however, those results were overestimated.35 Most recent meta‐analyses evaluated only the short‐term clinical outcomes of manual thrombus aspiration and showed the lack of short‐term clinical benefits, mainly driven by 2 trials: TOTAL and TASTE.10, 39 In our meta‐analysis, we only focused on the long‐term clinical outcomes beyond 6 months; however, some limitations were noticed. First, lack of patient‐level data precluded further subgroup analyses to examine the effect of aspiration thrombectomy based on the timing from door to balloon, certain angiographic characteristics such as thrombus burden that could benefit from aspiration thrombectomy,40 or infarct‐related artery. Second, this study was not designed to evaluate the safety of aspiration thrombectomy (ie, stroke risk); however, a recent meta‐analysis of randomized trials suggested that the risk of stroke could be related to the patients’ characteristics rather than the procedure.12 Third, the primary outcome of many of the trials included was surrogate markers of myocardial reperfusion, not clinical outcomes; however, we included all the available studies to date in an attempt to minimize publication bias.

CONCLUSION

Routine aspiration thrombectomy prior to primary PCI does not appear to have any benefit on long‐term clinical outcomes. Further randomized trials are recommended to evaluate the benefit of aspiration thrombectomy in selected patient populations and coronary lesions.

Author Contributions

AE and IE: acquisition of data, analysis and interpretation of data, drafting the article, final approval. AM: analysis and interpretation of data, drafting the article, final approval. AB: conception and design of the study, critical revision, final approval.

Conflicts of Interest

Anthony A. Bavry discloses honorarium of the American College of Cardiology. All other authors declare no potential conflicts of interest.

Supporting information

Supplement Figure 1: Sensitivity analysis with summary random effects odds ratio for all‐cause mortality for trials with low risk of bias versus trials with high risk of bias.

Click here for additional data file.^{(424KB, tif)}

Supplement Figure 2: Sensitivity analysis with summary random effects odds ratio for all‐cause mortality for large trials with ≥ 1000 patients versus small trials with < 1000 patients.

Click here for additional data file.^{(426.5KB, tif)}

Supplement Figure 3: Summary random effects odds ratio for re‐infarction.

Click here for additional data file.^{(362.3KB, tif)}

Supplement Figure 4: Summary random effects odds ratio for cardiovascular mortality.

Click here for additional data file.^{(297.5KB, tif)}

Supplement Figure 5: Summary random effects odds ratio for stent thrombosis.

Click here for additional data file.^{(305.4KB, tif)}

Supplement Table1: Cochrane risk of bias assessment tool for the individual trials.

Supplement Table 2: The quality measures of the individual trials included.

Click here for additional data file.^{(39.8KB, docx)}

Elgendy AY, Elgendy IY, Mahmoud AN and Bavry AA. Long‐term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta‐analysis of randomized trials. Clin Cardiol. 2017;40:534–541. 10.1002/clc.22691

REFERENCES

1. Menees DS, Peterson ED, Wang Y, et al. Door‐to‐balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013;369:901–909. [DOI] [PubMed] [Google Scholar]
2. Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI Focused Update on primary percutaneous coronary intervention for patients with ST‐elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST‐elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2016;133:1135 – 1147. [DOI] [PubMed] [Google Scholar]
3. Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST‐elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published corrections appear in J Am Coll Cardiol. 2009;54:2464 and 2009;55:612]. J Am Coll Cardiol . 2009;54:2205 – 2241. [DOI] [PubMed] [Google Scholar]
4. Jaffe R, Charron T, Puley G, et al. Microvascular obstruction and the no‐reflow phenomenon after percutaneous coronary intervention. Circulation. 2008;117:3152 – 3156. [DOI] [PubMed] [Google Scholar]
5. Stone GW, Peterson MA, Lansky AJ, et al. Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol. 2002;39:591 – 597. [DOI] [PubMed] [Google Scholar]
6. Mahmoud AN, Elgendy IY, Bavry AA. Current considerations of thrombectomy for acute myocardial infarction. Cardiovasc Innov Appl. 2016;1:265 – 272. [Google Scholar]
7. Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta‐analysis of randomized trials. Eur Heart J. 2008;24:2989–3001. [DOI] [PubMed] [Google Scholar]
8. Lagerqvist B, Fröbert O, Olivecrona GK, et al. Outcomes 1 year after thrombus aspiration for myocardial infarction. N Engl J Med. 2014;371:1111 – 1120. [DOI] [PubMed] [Google Scholar]
9. Jolly SS, Cairns JA, Yusuf S, et al; TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med . 2015;372:1389 – 1398. [DOI] [PMC free article] [PubMed] [Google Scholar]
10. Elgendy IY, Huo T, Bhatt DL, et al. Is aspiration thrombectomy beneficial in patients undergoing primary percutaneous coronary intervention? Meta‐analysis of randomized trials. Circ Cardiovasc Interv . 2015;8:e002258. [DOI] [PubMed] [Google Scholar]
11. Jolly SS, Cairns JA, Yusuf S, et al. Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1‐year follow‐up of the prospective randomised TOTAL trial. Lancet. 2016;387:127–135. [DOI] [PMC free article] [PubMed] [Google Scholar]
12. Mahmoud AN, Bavry AA, Elgendy IY. The risk for stroke with aspiration thrombectomy: procedure or patient related?: insights from a meta‐analysis. JACC Cardiovasc Interv. 2016;9:1750 – 1752. [DOI] [PubMed] [Google Scholar]
13. Kumbhani DJ, Bavry AA, Desai MY, et al. Aspiration thrombectomy in patients undergoing primary angioplasty: totality of data to 2013. Catheter Cardiovasc Interv. 2014;84:973 – 977. [DOI] [PubMed] [Google Scholar]
14. Hoole SP, Jaworski C, Brown AJ, et al. Serial assessment of the index of microcirculatory resistance during primary percutaneous coronary intervention comparing manual aspiration catheter thrombectomy with balloon angioplasty (IMPACT study): a randomised controlled pilot study. Open Heart. 2015;2:e000238. [DOI] [PMC free article] [PubMed] [Google Scholar]
15. Prati F, Romagnoli E, Limbruno U, et al. Randomized evaluation of intralesion versus intracoronary abciximab and aspiration thrombectomy in patients with ST‐elevation myocardial infarction: the COCTAIL II trial. Am Heart J. 2015;170:1116 – 1123. [DOI] [PubMed] [Google Scholar]
16. Shehata M. Angiographic and clinical impact of successful manual thrombus aspiration in diabetic patients undergoing primary PCI. Int J Vasc Med. 2014;2014:263926. [DOI] [PMC free article] [PubMed] [Google Scholar]
17. Turgeman Y, Bushari LI, Antonelli D, et al. Catheter aspiration after every stage during primary percutaneous angioplasty: ADMIT trial. Int J Angiol. 2014;23:29 – 40. [DOI] [PMC free article] [PubMed] [Google Scholar]
18. Sim DS, Ahn Y, Kim YH, et al. Effect of manual thrombus aspiration during primary percutaneous coronary intervention on infarct size: evaluation with cardiac computed tomography. Int J Cardiol. 2013;168:4328 – 4330. [DOI] [PubMed] [Google Scholar]
19. The Cochrane Collaboration In: Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions . Version 5.0.0. Published 2008. Accessed January 13, 2017. http://www.cochrane‐handbook.org. [Google Scholar]
20. Moher D, Liberati A, Tetzlaff J, et al; PRISMA Group . Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement. BMJ . 2009;339:b2535. [DOI] [PMC free article] [PubMed] [Google Scholar]
21. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Control Clin Trials. 1986;7:177 – 188. [DOI] [PubMed] [Google Scholar]
22. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta‐analyses. BMJ. 2003;327:557–560. [DOI] [PMC free article] [PubMed] [Google Scholar]
23. Egger M, Davey Smith G, Schneider M, et al. Bias in meta‐analysis detected by a simple, graphical test. BMJ. 1997;315:629 – 634. [DOI] [PMC free article] [PubMed] [Google Scholar]
24. Vlaar PJ, Svilaas T, van der Horst IC, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS): a 1‐year follow‐up study. Lancet. 2008;371:1915 – 1920. [DOI] [PubMed] [Google Scholar]
25. Stone GW, Witzenbichler B, Godlewski J, et al. Intralesional abciximab and thrombus aspiration in patients with large anterior myocardial infarction: one‐year results from the INFUSE‐AMI trial. Circ Cardiovasc Interv. 2013;6:527 – 534. [DOI] [PubMed] [Google Scholar]
26. Bulum J, Ernst A, Strozzi M. The impact of successful manual thrombus aspiration on in‐stent restenosis after primary PCI: angiographic and clinical follow‐up. Coron Artery Dis. 2012;23:487 – 491. [DOI] [PubMed] [Google Scholar]
27. De Carlo M, Aquaro GD, Palmieri C, et al. A prospective randomized trial of thrombectomy versus no thrombectomy in patients with ST‐segment elevation myocardial infarction and thrombus‐rich lesions: MUSTELA (Multidevice Thrombectomy in Acute ST‐Segment Elevation Acute Myocardial Infarction) trial. JACC Cardiovasc Interv. 2012;5:1223 – 1230. [DOI] [PubMed] [Google Scholar]
28. Dudek D, Mielecki W, Burzotta F, et al. Thrombus aspiration followed by direct stenting: a novel strategy of primary percutaneous coronary intervention in ST‐segment elevation myocardial infarction. Results of the Polish‐Italian‐Hungarian Randomized Thrombectomy Trial (PIHRATE Trial). Am Heart J . 2010;160:966 – 972. [DOI] [PubMed] [Google Scholar]
29. Liu CP, Lin MS, Chiu YW, et al. Additive benefit of glycoprotein IIb/IIIa inhibition and adjunctive thrombus aspiration during primary coronary intervention: results of the Initial Thrombosuction and Tirofiban Infusion (ITTI) trial. Int J Cardiol. 2012;156:174 – 179. [DOI] [PubMed] [Google Scholar]
30. Liistro F, Grotti S, Angioli P, et al. Impact of thrombus aspiration on myocardial tissue reperfusion and left ventricular functional recovery and remodeling after primary angioplasty. Circ Cardiovasc Interv. 2009;2:376 – 383. [DOI] [PubMed] [Google Scholar]
31. Sardella G, Mancone M, Bucciarelli‐Ducci C, et al. Thrombus aspiration during primary percutaneous coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (Thrombectomy With Export Catheter in Infarct‐related Artery During Primary Percutaneous Coronary Intervention) prospective, randomized trial. J Am Coll Cardiol. 2009;53:309 – 315. [DOI] [PubMed] [Google Scholar]
32. Ikari Y, Sakurada M, Kozuma K, et al; VAMPIRE Investigators . Upfront thrombus aspiration in primary coronary intervention for patients with ST‐segment elevation acute myocardial infarction: report of the VAMPIRE (Vacuum Aspiration Thrombus Removal) trial. JACC Cardiovasc Interv . 2008;1:424 – 431. [DOI] [PubMed] [Google Scholar]
33. Chao CL, Hung CS, Lin YH, et al. Time‐dependent benefit of initial thrombosuction on myocardial reperfusion in primary percutaneous coronary intervention. Int J Clin Pract. 2008;62:555 – 561. [DOI] [PubMed] [Google Scholar]
34. De Luca L, Sardella G, Davidson CJ, et al. Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST‐elevation myocardial infarction. Heart. 2006;92:951 – 957. [DOI] [PMC free article] [PubMed] [Google Scholar]
35. Kumbhani DJ, Bavry AA. The rise and fall of aspiration thrombectomy. JACC Cardiovasc Interv. 2016;9:135 – 137. [DOI] [PubMed] [Google Scholar]
36. Elgendy IY, Kumbhani DJ, Mahmoud A, et al. Mechanical thrombectomy for acute ischemic stroke: a meta‐analysis of randomized trials. J Am Coll Cardiol. 2015;66:2498 – 2505. [DOI] [PubMed] [Google Scholar]
37. Elgendy IY, Mahmoud AN, Mansoor H, et al. Evolution of acute ischemic stroke therapy from lysis to thrombectomy: similar or different to acute myocardial infarction? Int J Cardiol. 2016;222:441 – 447. [DOI] [PubMed] [Google Scholar]
38. Kumbhani DJ, Bavry AA, Desai MY, et al. Role of aspiration and mechanical thrombectomy in patients with acute myocardial infarction undergoing primary angioplasty: an updated meta‐analysis of randomized trials. J Am Coll Cardiol. 2013;62:1409 – 1418. [DOI] [PubMed] [Google Scholar]
39. El Dib R, Spencer FA, Suzumura EA, et al. Aspiration thrombectomy prior to percutaneous coronary intervention in ST‐elevation myocardial infarction: a systematic review and meta‐analysis. BMC Cardiovasc Disord. 2016;16:121. [DOI] [PMC free article] [PubMed] [Google Scholar]
40. Jolly SS, James S, Džavík V, et al. Thrombus aspiration in ST‐segment‐elevation myocardial infarction: an individual patient meta‐analysis: Thrombectomy Trialists Collaboration. Circulation. 2017;135:143 – 152. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement Figure 1: Sensitivity analysis with summary random effects odds ratio for all‐cause mortality for trials with low risk of bias versus trials with high risk of bias.

Click here for additional data file.^{(424KB, tif)}

Supplement Figure 2: Sensitivity analysis with summary random effects odds ratio for all‐cause mortality for large trials with ≥ 1000 patients versus small trials with < 1000 patients.

Click here for additional data file.^{(426.5KB, tif)}

Supplement Figure 3: Summary random effects odds ratio for re‐infarction.

Click here for additional data file.^{(362.3KB, tif)}

Supplement Figure 4: Summary random effects odds ratio for cardiovascular mortality.

Click here for additional data file.^{(297.5KB, tif)}

Supplement Figure 5: Summary random effects odds ratio for stent thrombosis.

Click here for additional data file.^{(305.4KB, tif)}

Supplement Table1: Cochrane risk of bias assessment tool for the individual trials.

Supplement Table 2: The quality measures of the individual trials included.

Click here for additional data file.^{(39.8KB, docx)}

[clc22691-bib-0001] 1. Menees DS, Peterson ED, Wang Y, et al. Door‐to‐balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013;369:901–909. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0002] 2. Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI Focused Update on primary percutaneous coronary intervention for patients with ST‐elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST‐elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2016;133:1135 – 1147. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0003] 3. Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST‐elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published corrections appear in J Am Coll Cardiol. 2009;54:2464 and 2009;55:612]. J Am Coll Cardiol . 2009;54:2205 – 2241. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0004] 4. Jaffe R, Charron T, Puley G, et al. Microvascular obstruction and the no‐reflow phenomenon after percutaneous coronary intervention. Circulation. 2008;117:3152 – 3156. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0005] 5. Stone GW, Peterson MA, Lansky AJ, et al. Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol. 2002;39:591 – 597. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0006] 6. Mahmoud AN, Elgendy IY, Bavry AA. Current considerations of thrombectomy for acute myocardial infarction. Cardiovasc Innov Appl. 2016;1:265 – 272. [Google Scholar]

[clc22691-bib-0007] 7. Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta‐analysis of randomized trials. Eur Heart J. 2008;24:2989–3001. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0008] 8. Lagerqvist B, Fröbert O, Olivecrona GK, et al. Outcomes 1 year after thrombus aspiration for myocardial infarction. N Engl J Med. 2014;371:1111 – 1120. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0009] 9. Jolly SS, Cairns JA, Yusuf S, et al; TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med . 2015;372:1389 – 1398. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0010] 10. Elgendy IY, Huo T, Bhatt DL, et al. Is aspiration thrombectomy beneficial in patients undergoing primary percutaneous coronary intervention? Meta‐analysis of randomized trials. Circ Cardiovasc Interv . 2015;8:e002258. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0011] 11. Jolly SS, Cairns JA, Yusuf S, et al. Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1‐year follow‐up of the prospective randomised TOTAL trial. Lancet. 2016;387:127–135. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0012] 12. Mahmoud AN, Bavry AA, Elgendy IY. The risk for stroke with aspiration thrombectomy: procedure or patient related?: insights from a meta‐analysis. JACC Cardiovasc Interv. 2016;9:1750 – 1752. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0013] 13. Kumbhani DJ, Bavry AA, Desai MY, et al. Aspiration thrombectomy in patients undergoing primary angioplasty: totality of data to 2013. Catheter Cardiovasc Interv. 2014;84:973 – 977. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0014] 14. Hoole SP, Jaworski C, Brown AJ, et al. Serial assessment of the index of microcirculatory resistance during primary percutaneous coronary intervention comparing manual aspiration catheter thrombectomy with balloon angioplasty (IMPACT study): a randomised controlled pilot study. Open Heart. 2015;2:e000238. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0015] 15. Prati F, Romagnoli E, Limbruno U, et al. Randomized evaluation of intralesion versus intracoronary abciximab and aspiration thrombectomy in patients with ST‐elevation myocardial infarction: the COCTAIL II trial. Am Heart J. 2015;170:1116 – 1123. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0016] 16. Shehata M. Angiographic and clinical impact of successful manual thrombus aspiration in diabetic patients undergoing primary PCI. Int J Vasc Med. 2014;2014:263926. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0017] 17. Turgeman Y, Bushari LI, Antonelli D, et al. Catheter aspiration after every stage during primary percutaneous angioplasty: ADMIT trial. Int J Angiol. 2014;23:29 – 40. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0018] 18. Sim DS, Ahn Y, Kim YH, et al. Effect of manual thrombus aspiration during primary percutaneous coronary intervention on infarct size: evaluation with cardiac computed tomography. Int J Cardiol. 2013;168:4328 – 4330. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0019] 19. The Cochrane Collaboration In: Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions . Version 5.0.0. Published 2008. Accessed January 13, 2017. http://www.cochrane‐handbook.org. [Google Scholar]

[clc22691-bib-0020] 20. Moher D, Liberati A, Tetzlaff J, et al; PRISMA Group . Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement. BMJ . 2009;339:b2535. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0021] 21. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Control Clin Trials. 1986;7:177 – 188. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0022] 22. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta‐analyses. BMJ. 2003;327:557–560. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0023] 23. Egger M, Davey Smith G, Schneider M, et al. Bias in meta‐analysis detected by a simple, graphical test. BMJ. 1997;315:629 – 634. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0024] 24. Vlaar PJ, Svilaas T, van der Horst IC, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS): a 1‐year follow‐up study. Lancet. 2008;371:1915 – 1920. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0025] 25. Stone GW, Witzenbichler B, Godlewski J, et al. Intralesional abciximab and thrombus aspiration in patients with large anterior myocardial infarction: one‐year results from the INFUSE‐AMI trial. Circ Cardiovasc Interv. 2013;6:527 – 534. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0026] 26. Bulum J, Ernst A, Strozzi M. The impact of successful manual thrombus aspiration on in‐stent restenosis after primary PCI: angiographic and clinical follow‐up. Coron Artery Dis. 2012;23:487 – 491. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0027] 27. De Carlo M, Aquaro GD, Palmieri C, et al. A prospective randomized trial of thrombectomy versus no thrombectomy in patients with ST‐segment elevation myocardial infarction and thrombus‐rich lesions: MUSTELA (Multidevice Thrombectomy in Acute ST‐Segment Elevation Acute Myocardial Infarction) trial. JACC Cardiovasc Interv. 2012;5:1223 – 1230. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0028] 28. Dudek D, Mielecki W, Burzotta F, et al. Thrombus aspiration followed by direct stenting: a novel strategy of primary percutaneous coronary intervention in ST‐segment elevation myocardial infarction. Results of the Polish‐Italian‐Hungarian Randomized Thrombectomy Trial (PIHRATE Trial). Am Heart J . 2010;160:966 – 972. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0029] 29. Liu CP, Lin MS, Chiu YW, et al. Additive benefit of glycoprotein IIb/IIIa inhibition and adjunctive thrombus aspiration during primary coronary intervention: results of the Initial Thrombosuction and Tirofiban Infusion (ITTI) trial. Int J Cardiol. 2012;156:174 – 179. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0030] 30. Liistro F, Grotti S, Angioli P, et al. Impact of thrombus aspiration on myocardial tissue reperfusion and left ventricular functional recovery and remodeling after primary angioplasty. Circ Cardiovasc Interv. 2009;2:376 – 383. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0031] 31. Sardella G, Mancone M, Bucciarelli‐Ducci C, et al. Thrombus aspiration during primary percutaneous coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (Thrombectomy With Export Catheter in Infarct‐related Artery During Primary Percutaneous Coronary Intervention) prospective, randomized trial. J Am Coll Cardiol. 2009;53:309 – 315. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0032] 32. Ikari Y, Sakurada M, Kozuma K, et al; VAMPIRE Investigators . Upfront thrombus aspiration in primary coronary intervention for patients with ST‐segment elevation acute myocardial infarction: report of the VAMPIRE (Vacuum Aspiration Thrombus Removal) trial. JACC Cardiovasc Interv . 2008;1:424 – 431. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0033] 33. Chao CL, Hung CS, Lin YH, et al. Time‐dependent benefit of initial thrombosuction on myocardial reperfusion in primary percutaneous coronary intervention. Int J Clin Pract. 2008;62:555 – 561. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0034] 34. De Luca L, Sardella G, Davidson CJ, et al. Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST‐elevation myocardial infarction. Heart. 2006;92:951 – 957. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0035] 35. Kumbhani DJ, Bavry AA. The rise and fall of aspiration thrombectomy. JACC Cardiovasc Interv. 2016;9:135 – 137. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0036] 36. Elgendy IY, Kumbhani DJ, Mahmoud A, et al. Mechanical thrombectomy for acute ischemic stroke: a meta‐analysis of randomized trials. J Am Coll Cardiol. 2015;66:2498 – 2505. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0037] 37. Elgendy IY, Mahmoud AN, Mansoor H, et al. Evolution of acute ischemic stroke therapy from lysis to thrombectomy: similar or different to acute myocardial infarction? Int J Cardiol. 2016;222:441 – 447. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0038] 38. Kumbhani DJ, Bavry AA, Desai MY, et al. Role of aspiration and mechanical thrombectomy in patients with acute myocardial infarction undergoing primary angioplasty: an updated meta‐analysis of randomized trials. J Am Coll Cardiol. 2013;62:1409 – 1418. [DOI] [PubMed] [Google Scholar]

[clc22691-bib-0039] 39. El Dib R, Spencer FA, Suzumura EA, et al. Aspiration thrombectomy prior to percutaneous coronary intervention in ST‐elevation myocardial infarction: a systematic review and meta‐analysis. BMC Cardiovasc Disord. 2016;16:121. [DOI] [PMC free article] [PubMed] [Google Scholar]

[clc22691-bib-0040] 40. Jolly SS, James S, Džavík V, et al. Thrombus aspiration in ST‐segment‐elevation myocardial infarction: an individual patient meta‐analysis: Thrombectomy Trialists Collaboration. Circulation. 2017;135:143 – 152. [DOI] [PubMed] [Google Scholar]

PERMALINK

Long‐term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta‐analysis of randomized trials

Akram Y Elgendy

Islam Y Elgendy

Ahmed N Mahmoud

Anthony A Bavry

Abstract

INTRODUCTION