Addition of eptifibatide and manual thrombus aspiration to ticagrelor does not improve long-term survival after STEMI treated with primary PCI.

Background: Current guidelines recommend that glycoprotein IIb/IIIa inhibitor (GPI) and manual aspiration thrombectomy should not be routinely used in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI), although there is a lack of dedicated studies. The aim of this study was to examine the impact of combined usage of a potent P2Y12 inhibitor, GPI, and manual aspiration thrombectomy on long-term survival after STEMI. Methods: All STEMI patients treated by pPCI in a tertiary center who have been included prospectively in the local PCI registry between January 2016 and December 2022 were analyzed in this study. Patients were excluded if they required oral anticoagulation or bridging between clopidogrel or ticagrelor during hospitalization. Results: A total of 1,210 patients were included in the present study, with a median follow-up of 2.78 (1.00-4.88) years. Ticagrelor significantly reduced all-cause and cardiovascular-cause mortality [HR = 0.27 (0.21-0.34), p < 0.0001 and HR = 0.23 (0.17-0.30), p < 0.0001, respectively]. Eptifibatide significantly reduced all-cause and cardiovascular-cause mortality [HR = 0.72 (0.57-0.92), p = 0.002, and HR = 0.68 (0.52-0.89), p = 0.001, respectively]. Manual thrombus aspiration had no significant effect on both all-cause and cardiovascular-cause mortality. In multivariate Cox regression, all-cause mortality was reduced by ticagrelor, while eptifibatide or manual thrombus aspiration had no significant effect. However, cardiovascular-cause mortality was reduced by both ticagrelor and eptifibatide, while manual thrombus aspiration had no significant effect. Conclusion: Ticagrelor consistently reduced cardiovascular and all-cause mortality, while eptifibatide reduced only cardiovascular mortality. Manual thrombus aspiration provided no long-term benefit. Our findings support the current guideline recommendation that GPI and manual aspiration thrombectomy should not be routinely used in treatment of STEMI with pPCI.

Case Report: Thrombus aspiration and in situ thrombolysis via a Guidezilla guide extension catheter in a patient with high-risk pulmonary embolism.

Standard catheter-directed thrombolysis (CDT) and thrombus aspiration are considered potentially promising approaches for reopening the embolism-related pulmonary artery in patients with pulmonary embolism (PE) with high thrombotic burden and deteriorating hemodynamics, especially in those for whom systemic thrombolysis is contraindicated or has failed. However, the constrained accessibility of dedicated catheters has impeded the potential benefits of standard CDT in developing countries. The Guidezilla guide extension catheter (GEC) with a larger diameter and extended length is widely used in challenging coronary anatomy. Nevertheless, there have been few reports on the application of the Guidezilla GEC as a novel option for patients with massive PE when dedicated catheters and surgical thrombectomy are not available. In this case report, we demonstrated that thrombus aspiration and in situ thrombolysis through the Guidezilla GEC are applicable to patients with PE in whom systemic thrombolysis is contraindicated, resulting in successful reperfusion and positive clinical outcomes.

The Use of Thrombectomy during Primary Percutaneous Coronary Intervention: Resurrecting an Old Concept in Contemporary Practice.

Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.

Effects of Tirofiban in Patients with Acute Myocardial Infarction and Diabetes Mellitus undergoing Primary Percutaneous Coronary Intervention.

OBJECTIVE: This study evaluated the efficacy and safety of early vs. late tirofiban administration in the treatment of patients with acute ST-elevation myocardial infarction (STEMI) and diabetes mellitus (DM) undergoing primary percutaneous coronary intervention (pPCI). METHODS: 120 patients with STEMI and DM treated with pPCI were randomly divided into an observation group (n=60) and a control group (n=60). The observation group and the control group were intravenously injected with a bolus of tirofiban preoperatively or intraoperatively, respectively; both groups were then given an intravenous infusion over 24 h at 0.15 µg/kg/min. Thrombolysis in myocardial infarction (TIMI) grade flow, myocardial perfusion index, and functional heart parameters, as well as major adverse cardiovascular events and bleeding, were compared between the two groups. RESULTS: Functional heart parameters, including left ventricular ejection fraction and cardiac output, were significantly improved in the observation group 6 months after discharge. Thrombus aspiration, inflammatory factors, and cardiac troponin I (cTNI) were more significantly decreased in the observation group than in the control group. The sum-ST-segment elevation at 2 h after pPCI treatment in the observation group was better than that in the control group. There was no significant difference in the incidence of adverse reactions and bleeding between the two groups. CONCLUSION: The administration of tirofiban before reperfusion therapy compared with after reperfusion therapy is more effective in reducing the hyperthrombotic load, thrombus aspiration, inflammatory factors, and cTNI and can effectively improve myocardial perfusion and heart function.

Impact of thrombus aspiration on left ventricular remodeling and function in patients with ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials.

BACKGROUND: Routine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI). METHODS: PubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA. RESULTS: A total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to -0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to -3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = -2.13, p = 0.03; z = -3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04). CONCLUSION: TA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.

Effect of optimized thrombus aspiration on myocardial perfusion and prognosis in acute ST-segment elevation myocardial infarction patients with primary percutaneous coronary intervention.

Objective: To investigate the impact of optimized thrombus aspiration on myocardial perfusion, prognosis, and safety in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention(primary PCI). Methods: A total of 129 patients with STEMI were randomly allocated into control group (Subgroup A and B) and experimental group(Subgroup C and D). Control group received percutaneous transluminal coronary angioplasty (PTCA),thrombus aspiration and primary PCI. Experimental group received optimized thrombus aspiration and primary PCI. The number of thrombus aspiration was less than 4 times in Subgroup A and C. The number of thrombus aspiration was performed more than 4 times in Subgroups B and D. The classification of thrombi extracted, the TIMI flow grade, the incidence of no-reflow and slow flow, cTFC, TPI and CK-MB at 12 h and 24 h after stenting, ST segment resolution of ECG after stenting, NT-proBNP, LVEFat 24 h, 30 days and 180 days after stenting were compared between groups. The incidence of intraoperative and postoperative bleeding complications, stroke events and major cardiovascular events (MACE) were recorded and compared between groups. Results: The classification of thrombi extracted in the experimental group was higher than that in the control group. The TIMI flow grade of the experimental group was better than the control group after thrombus aspiration. After stenting, the advantage still existed, but the difference was not statistically significant. On cTFC, the experimental group was lower than the control group, but the difference was not statistically significant; After stenting the experimental group was significantly lower than the control group. The CK-MB at 12 h and 24 h of the experimental group was lower than the control group. After thrombus aspiration the incidence of no-reflow in the experimental group was significantly lower than that in the control group; after stenting the incidence of no-reflow in the experimental group was still lower than the control group, but no statistically difference. After thrombus aspiration and stenting the incidence of slow flow in the experimental group were lower than that in the control group. After stenting, NT-proBNP at 24 h was lower in the experimental group than that in the control group, However, there was no statistical difference; after stenting, The NT-proBNP in the experimental group was lower than that in the control group at 30 days and 180 days. After stenting, LVEF of the experimental group was significantly higher than the control group at 24 h and 30 days; superiority remained after 180 days but no statistical difference. There was no statistical difference between two groups for intraoperative and postoperative bleeding complications, stroke events, and MACE events. In Subgroup analysis,there was no significant difference in the classification of thrombi extracted, TIMI flow grade, cTFC, CK-MB,NT-proBNP and LVEF between group C and D, but group A was better than group B. Analysis of variance showed that the optimal number of suction was 4-5 times. Conclusions: Optimized thrombus aspiration can significantly improve myocardial perfusion and short-term and medium-term prognosis of STEMI patients after PCI, and reduce the incidence of slow flow and no-reflow. The optimal suction times were 4-5 times. Traditional aspiration method with more aspiration times is harmful to cardiac prognosis. Thrombus aspiration does not increase the incidence of stroke events and is safe.Clinical Trial Registration: identifier, ChiCTR2300073410.

Prognostic value and clinical usefulness of PIANO score in patients undergoing primary percutaneous coronary intervention.

BACKGROUND: In our previous study, the PIANO score was constructed to predict the occurrence of no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention (PCI). In the current analysis, we sought to evaluate the prognostic value and clinical usefulness of the PIANO score in this population. METHODS: Patients with acute myocardial infarction (AMI) undergoing primary PCI were consecutively enrolled and followed up in this register. The endpoint of interest was all-cause mortality at 2 years after the procedure. The clinical benefits of thrombus aspiration (TA) during primary PCI in certain subgroups were also evaluated as exploratory analyses. RESULTS: A total of 2100 patients were identified, and 54.3% had high (≥8) PIANO score. After 2-year follow-up, patients with high PIANO score had higher risk of all-cause mortality after adjustment for propensity score (6.7% vs. 3.1%, adjusted hazard ratio = 2.11 [1.21-3.68], p = 0.008), especially in the first month (adjusted hazard ratio = 2.33 [1.17-4.65], p = 0.017). Restricted cubic spline analysis indicated the linear association between the PIANO score and 2-year all-cause mortality (nonlinear p = 0.556). Further analysis demonstrated that TA did not reduce all-cause mortality in the overall patients, as well as in those with visible thrombus, high thrombus burden, or occlusive lesions. However, the PIANO score defined "high-risk" (PIANO score ≥ 8) patients could benefit from it. CONCLUSIONS: The PIANO score had potential prognostic value in patients with AMI undergoing primary PCI. It might also be helpful for identifying patients who would benefit from TA. These observations require further confirmation in future studies.

Mortality across treatment strategies in intermediate-to-high risk pulmonary embolism in the modern era: A meta-analysis of observational studies and RCTs.

INTRODUCTION: Pulmonary embolism (PE) represents one of the leading causes of death worldwide and mainly treated with medical management, although the utility of more invasive approaches has emerged more recently. This meta-analysis aims to evaluate the 30-day mortality of intermediate-to-high risk PE across different treatment strategies. METHODS: A systematic literature review and meta-analysis was conducted using PubMed and Cochrane databases. All studies reporting 30-day mortality rates in intermediate-to-high-risk PE were included. Meta-regression analysis and sensitivity analysis were performed on the primary endpoint, 30-day mortality, and secondary endpoints (RV/LV ratio, mPAP, and long-term mortality, any bleeding events). RESULTS: Of the 2390 studies published between 2000 and 2022, 76 studies (74 observational and 2 RCTs for a total of 1,194,285 patients in the medical cohort and 3007 in the interventional cohort) were included. The median age was 71.4 (IQR 62.8-77.3) years, 53.6% were women. 30-day mortality in the patients treated with medical management was 9.1% (6.6-12.6). In the interventional cohort, 30-day mortality was 2.1% (1.5-3.1) while the pre- vs post-procedure change in mean difference was -6.1 mmHg (-11.2 to -1.1) for mPAP and - 0.41 (-0.51 to - 0.31) for RV/LV ratio. The overall bleeding rate in the interventional cohort was 4.9% (CI 2.6-8.9), without differences between the two strategies (RR 1.26 CI 0.89-1.78). CONCLUSION: Intermediate-high-risk mortality in pulmonary embolisms treated with medical management remains high in the modern era. Despite the absence of comparative studies, an interventional approach may have a lower 30-day mortality rate and a good safety profile.

Atrial Fibrillation Related Coronary Embolism: Diagnosis in the Focus.

Atrial fibrillation (AF) is the most common arrhythmia in myocardial infarction (MI). AF can be caused by ischemia, and MI can be caused by AF. Additionally, 4-5% of MI cases are related to coronary embolism (CE), and one-third of cases are attributed to AF. Our aim was to investigate the prevalence of AF-related CE cases among 3 consecutive years of STEMI cases. We also aimed to reveal the diagnostic accuracy of the Shibata criteria scoring system and the role of thrombus aspiration. Among 1181 STEMI patients, 157 had AF (13.2%). By using the Shibata's diagnostic criteria, 10 cases were classified as 'definitive' and 31 as 'probable' CE. After re-evaluation, a further five cases were classified as 'definitive'. Further analysis of the 15 CE cases revealed that CE was more prevalent in patients with previously known (n = 10) compared to those with new-onset (n = 5) AF (16.7% vs. 5.1%, p = 0.024). A PubMed search was performed, and 40 AF-related cases were found where the Shibata's criteria could be applied. Further, 31 cases could be classified as 'definitive', 4 as 'probable' and, in 5 cases, the embolic origin could be excluded. In 40% of reported cases and in 47% of our cases, thrombus aspiration helped in diagnosis.

Effectiveness of the vacuum assisted aspiration AngioVac system in the removal of intravascular masses.

BACKGROUND: Invasive procedures used to manage intravascular masses such as vegetation from endocarditis, deep vein thrombosis, and septic emboli are associated with high rates of complications and mortality, especially in patients with several pre-existing comorbidities. A minimally invasive technique that has become more popular in recent years is the AngioVac procedure. This single-centered, retrospective study focuses on patient presenting comorbidities and indications for the procedure as well as postprocedural outcomes. METHODS: A total of 33 patients who underwent an AngioVac procedure at Sanford Health between March 2014 and October 2019 was reviewed. Data were collected on pre-existing comorbidities, indication of procedure, length of stay, and postoperative outcomes. RESULTS: We evaluated a total of 33 patients who underwent an AngioVac procedure for removal of intravascular mass. The most common indications for the procedure were endocarditis (24/33, 73%); intracardiac mass (5/33, 15%); and deep vein thrombosis or pulmonary embolism (2/33, 6%). Post-procedural blood transfusion was required in nearly half (15/33, 45%). Almost all patients (31/33, 94%) required intraoperative vasopressor use. Nearly all patients (32/33, 97%) were directed to the intensive care unit following the procedure with an average length of stay of 8 days (interquartile range: 3-13). Most common complications seen after the procedure were shock requiring vasopressors, (13/33, 39%), pleural effusion (9/33, 27%), and sepsis (4/33, 12%). Procedural success in this single-centered experience was 85% (28/33), which was defined as size reduction of the initial vegetation by >50% in the absence of severe intraoperative complications and absence of need for further valvular surgical intervention. CONCLUSION: For surgically high-risk patients, the AngioVac procedure may offer a less invasive option in the management of right sided endocarditis requiring vegetation debulking, intravascular thrombi or cardiac masses.

Rationale and Design of a Randomized Controlled Pilot Trial to Assess Stent Retriever Thrombectomy for Thrombus Burden Reduction in Patients with Acute Myocardial Infarction: The RETRIEVE-AMI Study.

BACKGROUND: ST-elevation myocardial infarction (STEMI) is typically caused by thrombotic occlusion of a coronary artery with subsequent hypoperfusion and myocardial necrosis. In approximately half of patients with STEMI, despite successful restoration of epicardial coronary patency, downstream myocardium perfusion remains impeded. Coronary microvascular injury is one of the key mechanisms behind suboptimal myocardial perfusion and it is primarily, yet not exclusively, related to distal embolization of atherothrombotic material following recanalization of the culprit artery. Routine manual thrombus-aspiration has failed to show clinical efficacy in this scenario. This could be related with limitations in technology adopted as well as patients' selection. To this end, we set out to explore the efficacy and safety of stent retriever-assisted thrombectomy based on clot-removal device routinely used in stroke intervention. STUDY DESIGN AND OBJECTIVES: The stent RETRIEVEr thrombectomy for thrombus burden reduction in patients with Acute Myocardial Infarction (RETRIEVE-AMI) study has been designed to establish whether stent retriever-based thrombectomy is safe and more efficacious in thrombus modification than the current standard of care: manual thrombus aspiration or stenting. The RETRIEVE-AMI trial will enrol 81 participants admitted for primary PCI for inferior STEMI. Participants will be 1:1:1 randomised to receive either standalone PCI, thrombus aspiration and PCI, or retriever-based thrombectomy and PCI. Change in thrombus burden will be assessed via optical coherence tomography imaging. A telephone follow-up at 6 months will be arranged. CONCLUSIONS: It is anticipated by the investigators that stent retriever thrombectomy will more effectively reduce the thrombotic burden compared to current standard of care whilst being clinically safe.

A rare mechanism of embolic stroke complicating coronary thrombus aspiration.

Aspiration thrombectomy is often performed in patients with acute myocardial infarction with high thrombus burden. Current guidelines, however, recommend against it because of stroke risk. We report a case of embolic stroke complicating coronary thrombus aspiration in a 62-year-old man. Aspiration thrombectomy during percutaneous coronary intervention migrated thrombus to the proximal right coronary artery (RCA), and the thrombus was subsequently released into the aorta by backflow of the contrast injection causing aspiration thrombectomy-associated stroke. This is an extremely rare mechanism by which complications arise from failed aspiration thrombectomy.

An aspiration catheter stuck in a patient with acute coronary syndrome: an unanticipated complication.

A 62-year-old man presented with ST-elevation myocardial infarction. Thrombectomy using an aspiration catheter was performed, but the wire lumen of the catheter had been torn during the catheter was removed. The aspiration catheter could not be retrieved into the guide catheter, and the entire system along with the guide catheter was removed.

Outcomes of thrombus aspiration during primary percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). AIM: To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI. METHODS: We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality. RESULTS: We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P < 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P < 0.01), and current smoking (40% vs 36%; P < 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P < 0.01) with TIMI 0 flow (77% vs 56%; P < 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63-0.89; P < 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85-1.1; P = 0.73). CONCLUSION: The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.

Iatrogenic Dissection of the Left Internal Mammary Artery During Percutaneous Coronary Intervention of Jump Radial Artery Graft Bifurcation Disease: A Case Report.

Guide-catheter-induced ostial coronary artery dissection is a feared complication of percutaneous coronary intervention, but thankfully the incidence is low. We describe a case of catheter-induced ostial dissection of the left internal mammary artery (LIMA) with multiple radial jump grafts during percutaneous coronary intervention of radial graft bifurcation disease via the LIMA. The dissection led to loss of flow and profound haemodynamic compromise and cardiac arrest as the LIMA supplied the majority of the myocardium in this patient. Intravascular ultrasound was not immediately available, so an Export AP thrombus aspiration catheter (Medtronic) was used over the coronary wire in place to allow the injection of contrast while simultaneously pulling back on the catheter to delineate the extent of the dissection and guide accurate drug-eluting stent placement. The report is a cautionary tale to the reader to treat the LIMA with respect and think long and hard before considering any interventional procedure that uses the LIMA as a conduit.

Benefits of excimer laser coronary angioplasty over thrombus aspiration therapy for patients with acute coronary syndrome and thrombolysis in myocardial infarction flow grade 0.

In primary percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), the presence of a thrombus or unstable plaque can cause microvascular obstructions, which may increase infarct size and reduce survival. Excimer laser coronary angioplasty (ELCA) is a unique revascularization technique that can vaporize plaques and thrombi. However, to date, only few reports indicate the efficacy of ELCA for ACS. We retrospectively analyzed 113 consecutive ACS patients who underwent PCI with either ELCA or manual thrombus aspiration therapy (TA) before balloon angioplasty or stenting and who had a Thrombolysis in Myocardial Infarction flow (TIMI) grade 0 on the first contrast injection within 24 h of onset at our hospital from March 2011 to March 2020. Patients were divided into two groups by the procedure used: ELCA (N = 48) and TA (N = 50). Door-to-reperfusion time was significantly shorter in the ELCA group than TA group (89.2 ± 6.7 vs. 137.9 ± 12.3 min, respectively; P < 0.01). There was also a significant difference in peak creatine kinase-myocardial band between the ELCA and TA groups (242 ± 25 vs. 384 ± 63 IU/L, respectively; P = 0.04). Although there was no difference in myocardial blush grade (MBG) before treatment, the MBG after treatment was higher in the ELCA group (P < 0.01). In-hospital major adverse cardiac events (MACE) were also significantly fewer in the ELCA group than in the TA group (8% vs. 20%, P = 0.045). ELCA for TIMI grade 0 ACS may shorten reperfusion time, improve the MBG score, and reduce MACE when compared to TA.