Tips and tricks for thrombus aspiration in STEMI

Some issues of thrombus aspiration

• Thrombus presence is associated with adverse clinical outcomes

• Thrombus aspiration can be performed successfully in most

patients with acute STEMI; often leads to better reperfusion.

• Potential complications include distal embolization, endothelial

damage from forceful aspiration and trauma to tortuous

proximal vessels from the aspiration device.

• Data have changed from TAPAS (2008) to TASTE (2013) &

TOTAL (2015)

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Tips and tricks for 
thrombus aspiration in STEMI 
Dinh Duc Huy, MD, FSCAI 
Tam Duc Heart Hospital 
STEMI PPCI is complex! 
Some issues of thrombus aspiration 
• Thrombus presence is associated with adverse clinical outcomes 
• Thrombus aspiration can be performed successfully in most 
patients with acute STEMI; often leads to better reperfusion. 
• Potential complications include distal embolization, endothelial 
damage from forceful aspiration and trauma to tortuous 
proximal vessels from the aspiration device. 
• Data have changed from TAPAS (2008)  to TASTE (2013) & 
TOTAL (2015) 
• Single center, prospective, randomized 
• 1,071 patients with STEMI 
• Randomized 1:1 before angiography 
• Primary endpoint 
– Myocardial blush grade (core lab) 
• Secondary endpoints 
– ST-segment elevation resolution 
– 30 day death and death/ reinfarction 
– 1-year death and death/ reinfarction 
N Engl J Med 2008;358:557-67. 
TAPAS- 1 year clinical outcomes 
Time (days)
0 100 200 300 400
M
o
rt
a
lit
y
 (
%
)
0
2
4
6
8
10
12
Conventional PCI
Thrombus-Aspiration
Log-Rank p = 0.040 
Mortality 
Time (days)
0 100 200 300 400
D
e
a
th
 o
r 
R
e
in
fa
rc
ti
o
n
 (
%
)
0
2
4
6
8
10
12 Conventional PCI
Thrombus-Aspiration
Death or Re-infarction 
Log-Rank p = 0.016 
N Engl J Med 2008;358:557-67. 
Thrombus aspiration results in a lower mortality and 
combined mortality/non-fatal reinfarction 
0 1000 2000 3000 4000 5000 6000 7000 8000
Liistro
DEAR-MI
EXPIRA
PIHRATE
X AMINE ST
MUSTELA
Kaltoft
Chevalier
PREPARE
VAMPIRE
INFUSE-AMI
AIMI
JETSTENT
TAPAS
TASTE
Number of patients 
TASTE and previous studies 
• 7244 patients with STEMI 
• 3621 manual thrombus 
aspiration followed by PCI 
• 3623 PCI only 
• The primary end point was 
all-cause mortality at 30 
days 
N Engl J Med 2013;369:1587-97 
TASTE results at 30 days 
No benefit of manual thrombus aspiration 
as a routine adjunct to PCI in STEMI 
HR 0.94 (0.72 - 1.22), P=0.63 HR 0.61 (0.34 - 1.07), P=0.09 
Mortality Re-infarction 
N Engl J Med 2013;369:1587-97 
The TOTAL Trial Study Design 
PCI Alone 
(only bailout thrombectomy) 
Routine Upfront Manual 
Thrombectomy 
followed by PCI 
Primary Outcome: CV death, MI, cardiogenic shock and class IV 
heart failure ≤180 days 
Safety Outcome: Stroke ≤30 days 
1:1 Randomization between strategies 
Bailout Thrombectomy allowed if PCI alone strategy fails: 
• Persistent TIMI 0 or 1 flow with large thrombus after balloon pre-dilatation 
• Persistent large thrombus after stent deployment at target lesion 
STEMI* with Primary PCI ≤12 hours of symptom onset 
Sample size of 10,700 for 80% power to detect a 20% Relative Risk Reduction 
Jolly SS. N Engl J Med 2015;372:1389-98. 
 Day 180 
Thrombectomy 
(N=5033) (%) 
PCI alone 
(N=5030) (%) 
HR 95% CI p 
CV death, MI, shock or 
class IV heart failure 
347 (6.9%) 351 (7.0%) 0.99 0.85-1.15 0.86 
 CV death 157 (3.1%) 174 (3.5%) 0.90 0.73-1.12 0.34 
 Recurrent MI 99 (2.0%) 92 (1.8%) 1.07 0.81-1.43 0.62 
 Cardiogenic Shock 92 (1.8%) 100 (2.0%) 0.92 0.69-1.22 0.56 
 Class IV CHF 98 (1.9%) 90 (1.8%) 1.09 0.82-1.45 0.57 
Stroke within 30 days 33 (0.7%) 16 (0.3%) 2.06 1.13-3.75 0.015 
Stroke or TIA within 30 days 42 (0.8%) 19 (0.4%) 2.21 1.29-3.80 0.003 
Stroke within 180 days 52 (1.0%) 25 (0.5%) 2.08 1.29-3.35 0.002 
TOTAL Primary outcomes & safety outcomes 
2015 ACC/AHA/SCAI Focused Update on 
Primary PCI 
A suggested clinical algorithm 
during primary PCI 
Dharma S, Kedev S, Jukema JW. Heart 2013;99:279-284 
Things to be prepared for thrombus aspiration 
• Data- Level of evidence. 
• Thrombus burden (large, small, none) 
• Which aspiration devices to be used? 
• Size 6 Fr. or 7 Fr.? 
• Distal protection? 
• How many runs? 
Different devices 
Different profiles 
Manual versus Non-manual 
Gu YL, Zijlstra F. In: Oxford Textbook of Interventional Cardiology, 2010 
Tips for thrombus aspiration 
 Selection of guide, 6 Fr. system in the small/mid size vessel, 7 Fr. 
in the large vessel. Good guide support is important. 
 Gentle advancing the catheter (can easily kink). 
 Keep guide deeply engaged may help to avoid systemic 
embolization. 
 Start aspiration 2 cm before the lesion with the thrombus, move 
the catheter forward very slowly and pass the lesion with 
continuous aspiration. 
 Remove the catheter with aspiration even into the guide 
catheter, aspirate the blood from the guide catheter. 
 Remove the catheter outside slowly if a large thrombus is caught 
on the tip of catheter and completely block the aspiration. 
 Multiple attempts (according to angiographic result). 
 5 Fr. ST01 “Child” catheter in 6Fr./ 7Fr. “ Mother” Guide may 
help to aspirate big and old thrombus in late presented AMI. 
Tips for thrombus aspiration (cont.) 
Thank you for your attention! 

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