To Whom Thrombus Aspiration May Concern?
DOI:
https://doi.org/10.3889/oamjms.2019.546Keywords:
Primary cutaneous coronary intervention, Thrombus AspirationAbstract
BACKGROUND: Thrombus aspiration for ST-segment elevation myocardial infarction (STEMI) may improve myocardial perfusion. However, these favourable results called into a question by data indicating not only a lack of efficacy but a risk of potentially deleterious complications.
AIM: To assess the effect of thrombus aspiration during the primary percutaneous coronary intervention (PPCI) on procedural angiographic results, stent characteristics, and major adverse cardiac and cerebrovascular events (MACCE).
METHODS: All consecutive STEMI patients candidate for PPCI and admitted to Critical Care Department, Cairo University hospitals, managed either by thrombectomy before primary PCI (if thrombus score ≥ 3) or conventional PPCI, Six hundred seven subjects were enrolled in the study divided into Group with thrombectomy before PPCI (107 subjects, 18%), and group with Conventional PCI (500 subjects, 82%). ST-segment resolution, peak CK-MB, TIMI score, thrombus score, and MBG were assessed; stent number, diameter, length and stented segment were reported and follow up MACCE was reported (in hospital and 1-year post-intervention).
RESULTS: Mean values for peak CKMB were less in thrombectomy group (228 ± 174 I/U vs 269 ± 186 I/U, p = 0.04), ST segment resolution ≥ 70% occurred in {63 subjects (58.9%) vs 233 (46.6%), p = 0.001} in thrombectomy vs conventional group respectively. TIMI score pre procedure was zero in (102 subjects (95%) vs 402 (80.4%), p = 0.001), while TIMI III post procedure was reported in (100 subjects (93.4%) vs 437 (87%), p = 0.06), MBG mean values were (2.4 ± 0.6 vs 2.0 ± 1, p = 0.001), thrombus score was higher in thrombectomy group (4.6 ± 0.4 vs 0.8 ± 1.7, p = 0.001) in thrombectomy vs conventional group respectively .Direct stenting was { 34 patients (31%) vs 102 patients (20%), p = 0.05} , mean stent diameter (2.7 ± 1.3 mm vs 3.5 ± 1.3 mm, p = 0.3), mean stent length was (19.9 mm ± 10 versus 22.7 mm ± 8 in p 0.01). mean stent number was (1.0 ± 0.5 vs 1.2 ± 0.6, p = 0.001), mean stented segment was (22.5 ± 13.5 vs 28.5 ± 15.2 mm, p = 0.001) in thrombectomy vs conventional group respectively. MACCE in hospital were reported in {9 subjects (8.4%) vs 70 (14%), p = 0.07)}. Follow up MACCE after 1 year reported in {6 subjects (5.6 %) vs 80 (16 %), p 0.= 4} in thrombectomy vs conventional group respectively.
CONCLUSION: Thrombus aspiration before primary PCI (in a selected group with thrombus score ≥ 3) improves myocardial perfusion, suggested by better ST-segment resolution, TIMI flow, less peak CKMB and MBG, associated with a higher rate of direct stenting, shorter stent length, stented segments and less number of stents. Although thrombus aspiration was done in more risky patients (higher thrombus score) MACCE (in hospital and 1 year follow up) showed no statistical difference.
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References
Topol EJ YJ. Recognition of the importance of embolization in atherosclerotic vascular disease. Circ J. 2000; https://doi.org/10.1161/01.CIR.101.5.570 PMid:10662756
Vlaar PJ, Svilaas T, van der Horst IC, Diercks GFH, Fokkema ML, de Smet BJGL, 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(9628):1915-20. https://doi.org/10.1016/S0140-6736(08)60833-8
Svilaas T, Vlaar PJ, van der Horst IC, Diercks GFH, de Smet BJGL, van den Heuvel AFM, et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med. 2008; 358(6):557-67. https://doi.org/10.1056/NEJMoa0706416 PMid:18256391
Desch S, Stiermaier T, De Waha S, Lurz P, Gutberlet M, Sandri M, et al. Thrombus Aspiration in Patients with ST-Segment Elevation Myocardial Infarction Presenting Late after Symptom Onset. JACC Cardiovasc Interv. 2016; 9(2):113-22. https://doi.org/10.1016/j.jcin.2015.09.010 PMid:26793952
Bhindi R, Kajander OA, Jolly SS, Kassam S, Lavi S, Niemelä K, et al. Culprit lesion thrombus burden after manual thrombectomy or percutaneous coronary intervention-alone in ST-segment elevation myocardial infarction: The optical coherence tomography sub-study of the TOTAL (ThrOmbecTomy versus PCI ALone) trial. Eur Heart J. 2015; 36(29):1892-900. https://doi.org/10.1093/eurheartj/ehv176 PMid:25994742 PMCid:PMC5061563
Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution. European Heart Journal. 2014; 35:2541-619. https://doi.org/10.1093/eurheartj/ehu278 PMid:25173339
Simes RJ, Topol EJ, Holmes DRJ, White HD, Rutsch WR, Vahanian A, et al. Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion. Importance of early and complete infarct artery reperfusion. GUSTO-I Investigators. Circulation. 1995; 91(7):1923-8. https://doi.org/10.1161/01.CIR.91.7.1923 PMid:7895348
American Diabetes Association. 2016 American Diabetes Association (ADA) Diabetes Guidelines Summary Recommendation from NDEI. Natl Diabetes Educ Initiat. 2016; 39(1):1-46.
Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2014; 129(25 suppl 2):S1-45. https://doi.org/10.1161/01.cir.0000437738.63853.7a PMid:24222016
NICE. Hypertension: Clinical management of primary hypertension in adults (NICE clinical guideline 127). NICE. 2011;(April 2007):38.
Yeboah J, Erbel R, Delaney JC, Nance R, Guo M, Bertoni AG, Budoff M, Moebus S, Jöckel KH, Burke GL, Wong ND. Development of a new diabetes risk prediction tool for incident coronary heart disease events: the Multi-Ethnic Study of Atherosclerosis and the Heinz Nixdorf Recall Study. Atherosclerosis. 2014; 236(2):411-7. https://doi.org/10.1016/j.atherosclerosis.2014.07.035 PMid:25150939 PMCid:PMC4170005
Gibson CM, Cannon CP, Murphy SA, Ryan KA, Mesley R, Marble SJ, et al. Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs. Circulation. 2000; 101(2):125-30. https://doi.org/10.1161/01.CIR.101.2.125 PMid:10637197
Yamamuro A, Akasaka T, Tamita K, Yamabe K, Katayama M, Takagi T, et al. Coronary flow velocity pattern immediately after percutaneous coronary intervention as a predictor of complications and in-hospital survival after acute myocardial infarction. Circulation. 2002; 106(24):3051-6. https://doi.org/10.1161/01.CIR.0000043022.44032.77 PMid:12473550
Gibson CM, de Lemos J a, Murphy S a, Marble SJ, McCabe CH, Cannon CP, et al. Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: a TIMI 14 substudy. Circulation. 2001; 103(21):2550-4. https://doi.org/10.1161/01.CIR.103.21.2550 PMid:11382722
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012; 2(1):1-138.
Napodano M, Ramondo A, Tarantini G, Peluso D, Compagno S, Fraccaro C, et al. Predictors and time-related impact of distal embolization during primary angioplasty. Eur Heart J. 2009; 30(3):305-13. https://doi.org/10.1093/eurheartj/ehn594 PMid:19153179
Izgi A, Kirma C, Tanalp AC, Dundar C, Oduncu V, Aung SM, et al. Predictors and clinical significance of angiographically detected distal embolization after primary percutaneous coronary interventions. Coron Artery Dis. 2007; 18(6):443-9. https://doi.org/10.1097/MCA.0b013e3282a3064e PMid:17700215
Fröbert O, Lagerqvist B, Olivecrona GK, Omerovic E, Gudnason T, Maeng M, et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med. 2013; 369(17):1587-97. https://doi.org/10.1056/NEJMoa1308789 PMid:23991656
Kumbhani DJ, Bavry AA, Desai MY, Bangalore S, Bhatt DL. 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(16):1409-18. https://doi.org/10.1016/j.jacc.2013.04.025 PMid:23665372
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, De Lemos JA, et al. 2013 ACCF/AHA guideline for the management of st-elevation myocardial infarction: A report of the American college of cardiology foundation/american heart association task force on practice guidelines. Vol. 61, Journal of the American College of Cardiology. 2013.
Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ, et al. Randomized Trial of Primary PCI with or without Routine Manual Thrombectomy. N Engl J Med. 2015; 372(15):1389-98. https://doi.org/10.1056/NEJMoa1415098 PMid:25853743 PMCid:PMC4995102
Mastoris I, Giustino G, Sartori S, Baber U, Mehran R, Kini AS, et al. Efficacy and safety of routine thrombus aspiration in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: An updated systematic review and meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv. 2016; 87(4):650-60. https://doi.org/10.1002/ccd.26152 PMid:26994974
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN. 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. Journal of the American College of Cardiology. 2016; 67(10):1235-50. https://doi.org/10.1016/j.jacc.2015.10.005 PMid:26498666
Authors/Task Force Members, Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). European heart journal. 2012; 33(20):2569-619. https://doi.org/10.1093/eurheartj/ehs215 PMid:22922416
Silva-Orrego P, Colombo P, Bigi R, Gregori D, Delgado A, Salvade P, et al. Thrombus Aspiration Before Primary Angioplasty Improves Myocardial Reperfusion in Acute Myocardial Infarction. The DEAR-MI (Dethrombosis to Enhance Acute Reperfusion in Myocardial Infarction) Study. J Am Coll Cardiol. 2006; 48(8):1552-9. https://doi.org/10.1016/j.jacc.2006.03.068 PMid:17045887
Hamon M, Richardeau Y, Lecluse E, Saloux E, Sabatier R, Agostini D, et al. Direct coronary stenting without balloon predilation in acute coronary syndromes. Am Heart J. 1999; 138(1 I):55-9. https://doi.org/10.1016/S0002-8703(99)70246-2
Wilson SH, Berger PB, Mathew V, Bell MR, Garratt KN, Rihal CS, et al. Immediate and late outcomes after direct stent implantation without balloon predilation. J Am Coll Cardiol. 2000; 35(4):937-43. https://doi.org/10.1016/S0735-1097(99)00639-7
Diego Fernández-RodrÃguez, Luis Alvarez-Contreras, Victoria MartÃn-Yuste, Salvatore Brugaletta I, Ferreira, Marta De Antonio, Montserrat Cardona, Vicens MartÃ, Juan GarcÃa-Picart MS. Does manual thrombus aspiration help optimize stent implantation in ST-segment elevation myocardial infarction? World J Cardiol. 2014; 6(9)1030-1037. https://doi.org/10.4330/wjc.v6.i9.1030 PMid:25276303 PMCid:PMC4176794
Yamaguchi T, Kubo T, Ino Y, Matsuo Y, Shiono Y, Yamano T, Taruya A, Nishiguchi T, Shimokado A, Orii M, Tanaka A. Optical coherence tomography assessment of efficacy of thrombus aspiration in patients undergoing a primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. Coronary artery disease. 2015; 26(7). https://doi.org/10.1097/MCA.0000000000000291 PMid:26230885 PMCid:PMC4588603
Lemos PA, Van Mieghem CAG, Arampatzis CA, Hoye A, Ong ATL, McFadden E, et al. Post-sirolimus-eluting stent restenosis treated with repeat percutaneous intervention: Late angiographic and clinical outcomes. Circulation. 2004; 109(21):2500-2. https://doi.org/10.1161/01.CIR.0000130173.63105.4E PMid:15148279
Holmes DR, Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG, Williams DO, Kimura T, Moliterno DJ. Stent thrombosis. Journal of the American College of Cardiology. 2010; 56(17):1357-65. https://doi.org/10.1016/j.jacc.2010.07.016 PMid:20946992
Brodie B, Pokharel Y, Garg A, Kissling G, Hansen C, Milks S, et al. Predictors of early, late, and very late stent thrombosis after primary percutaneous coronary intervention with bare-metal and drug-eluting stents for st-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2012; 5(10):1043-51. https://doi.org/10.1016/j.jcin.2012.06.013 PMid:23078734
Costa MA, Simon DI. Molecular basis of restenosis and drug-eluting stents. Circulation. 2005; 111(17):2257-73. https://doi.org/10.1161/01.CIR.0000163587.36485.A7 PMid:15867193
Moses JW, Dangas G, Mehran R, Mintz GS. Drug-eluting stents in the real world: how intravascular ultrasound can improve clinical outcome. Am J Cardiol. 2008; 102(9 Suppl):24J-8J. https://doi.org/10.1016/j.amjcard.2008.09.006 PMid:18928789
Cutlip DE, Chauhan MS, Baim DS, Ho KKL, Popma JJ, Carrozza JP, et al. Clinical restenosis after coronary stenting: Perspectives from multicenter clinical trials. J Am Coll Cardiol. 2002; 40(12):2082-9. https://doi.org/10.1016/S0735-1097(02)02597-4
Kobayashi Y, De Gregorio J, Kobayashi N, Akiyama T, Reimers B, Finci L, et al. Stented segment length as an independent predictor of restenosis. J Am Coll Cardiol. 1999; 34(3):651-9. https://doi.org/10.1016/S0735-1097(99)00303-4
Mauri L, O'Malley AJ, Cutlip DE, Ho KKL, Popma JJ, Chauhan MS, et al. Effects of stent length and lesion length on coronary restenosis. Am J Cardiol. 2004; 93(11):1340-6. https://doi.org/10.1016/j.amjcard.2004.02.027 PMid:15165911
Rezkalla SH, Kloner RA. Coronary No-reflow Phenomenon. Curr Treat Options Cardiovasc Med. 2005; 7(1):75-80. https://doi.org/10.1007/s11936-005-0008-0
De Luca G, van't Hof AW, de Boer MJ, Hoorntje JC, Gosselink AM, Dambrink JH, Ottervanger JP, Zijlstra F, Suryapranata H. Impaired myocardial perfusion is a major explanation of the poor outcome observed in patients undergoing primary angioplasty for ST-segment-elevation myocardial infarction and signs of heart failure. Circulation. 2004; 109(8):958-61. https://doi.org/10.1161/01.CIR.0000120504.31457.28 PMid:14981008
Baks T, van Geuns RJ, Biagini E, Wielopolski P, Mollet NR, Cademartiri F, van der Giessen WJ, Krestin GP, Serruys PW, Duncker DJ, de Feyter PJ. Effects of primary angioplasty for acute myocardial infarction on early and late infarct size and left ventricular wall characteristics. Journal of the American College of Cardiology. 2006; 47(1):40-4. https://doi.org/10.1016/j.jacc.2005.09.008 PMid:16386662
Ghatak A, Singh V, Shantha GPS, Badheka A, Patel N, Alfonso CE, et al. Aspiration thrombectomy in patients undergoing primary angioplasty for ST elevation myocardial infarction: An updated meta-analysis. J Interv Cardiol. 2015; 28(6):503-13. https://doi.org/10.1111/joic.12249 PMid:26642999
Kumbhani DJ, Bavry AA, Desai MY, Bangalore S, Bhatt DL. 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(16):1409-18. https://doi.org/10.1016/j.jacc.2013.04.025 PMid:23665372
Elgendy IY, Huo T, Bhatt DL, Bavry AA. Is aspiration thrombectomy beneficial in patients undergoing primary percutaneous coronary intervention meta-Analysis of randomized trials. Circ Cardiovasc Interv. 2015; 8(7). https://doi.org/10.1161/CIRCINTERVENTIONS.114.002258
Jolly SS, Cairns JA, Yusuf S, Rokoss MJ, Gao P, Meeks B, et al. Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1-year follow-up of the prospective randomised TOTAL trial. Lancet. 2016; 387(10014):127-35. https://doi.org/10.1016/S0140-6736(15)00448-1
Sirker A, Mamas M, Kwok CS, Kontopantelis E, Ludman P, Hildick-Smith D. Outcomes From Selective Use of Thrombectomy in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: An Analysis of the British Cardiovascular Intervention Society/National Institute for Cardiovascu. JACC Cardiovasc Interv. 2016; 9(2):126-34. https://doi.org/10.1016/j.jcin.2015.10.047 PMid:26793954
Kumbhani DJ, Bavry AA, Desai MY, Bangalore S, Byrne RA, Jneid H, et al. Aspiration thrombectomy in patients undergoing primary angioplasty: Totality of data to 2013. Catheter Cardiovasc Interv. 2014; 84(6):973-7. https://doi.org/10.1002/ccd.25532 PMid:24782350
Jolly SS, Cairns JA, Yusuf S, Meeks B, Gao P, Hart RG, et al. Stroke in the TOTAL trial: A randomized trial of routine thrombectomy vs. percutaneous coronary intervention alone in ST elevation myocardial infarction. Eur Heart J. 2015; 36(35):2364-72. https://doi.org/10.1093/eurheartj/ehv296 PMid:26129947 PMCid:PMC4568405
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