Tips and tricks for thrombus aspiration in STEMI

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!