Thrombus aspiration during primary percutaneous coronary intervention for acute myocardial infarction: A review of clinical evidence and guidelines

Acute ST segment elevation myocardial infarction (STEMI) is characterized by complete thrombotic occlusion of a major coronary artery. Early recanalization of the infarct-related artery is most efficiently delivered by primary percutaneous coronary intervention (PPCI), however this does not always restore normal myocardial perfusion, mainly due to distal embolization of the thrombus and microvascular obstruction. Early evidence for manual thrombus aspiration during PPCI was promising and this was once considered an important aspect of the procedure, especially in patients with a high thrombus burden. However, a large body of evidence from recent major randomized controlled trials (notably TASTE and TOTAL) does not support the routine use of manual thrombus aspiration in patients with STEMI undergoing PPCI.     

血栓抽吸联合替罗非班治疗急性ST段抬高性心肌梗死

观察经皮冠状动脉介入（PCI）中血栓摘吸联合冠脉内注射替罗非班对急性心肌梗死（AMI）患者中的疗效。方法：选择2010年5月至2012年11月于黑龙江省红兴隆中心医院因AMI行直接PCI并于术中应用血栓抽吸联合冠脉内注射替罗非班的患者共58例,以单纯行PCI的61例患者作为对照,观察临床疗效。结果：与对照组比较,抽吸＋替罗非班组在同手术期大出血两组之间差异无统计学意义。罪犯血管术中术后血流情况、主要不良心血管事件发生率明显好于对照组,两组之间差异有统计学意义。结论：AMI患者行直接PCI前应用抽吸导管联合冠脉内注射替罗非班可明显减少无复流等并发症的发生,降低围手术期风险。     

Adjunctive thrombectomy in primary percutaneous intervention for acute myocardial infarction

Primary percutaneous coronary intervention (PCI) has become the favored reperfusion strategy in acute ST-segment elevation myocardial infarction. Lower post-PCI myocardial perfusion grade, no-reflow and even drug-eluting stent thrombosis have been related to the presence of intracoronary thrombus. Adjunctive thrombectomy refers to procedures and devices that remove thrombotic material from the infarction-related artery, in theory, before distal embolization can occur. There is substantial variability between randomized controlled trials of thrombectomy in primary PCI with regards to tested devices, procedural characteristics, adjuvant medical regimen and examined outcomes. As a general statement, improvements in myocardial perfusion endpoints do not translate into reductions in clinical outcomes. Yet, an increasing number of trials with a longer follow-up reported benefits arising late after the index myocardial infarction. Simple aspiration catheters may also produce better outcomes than devices that fragment the thrombus before aspirating debris. Clinical or angiographic variables which best predict benefits from the use of thrombectomy remain to be defined. The aim of this review is to provide perspective on the conclusions of available trials and meta-analysis of adjunctive thrombectomy in acute myocardial infarction. Targets for future studies are discussed.     

Use of microvena snare catheter in non-ST elevation myocardial infarction due to saphenous vein graft occlusive thrombi

A 75-year-old man presented with acute coronary syndrome; he had a saphenous vein graft thrombosis. Percutaneous coronary intervention of bypass graft vessels is more challenging due to a higher incidence of periprocedural distal micro-emobilization and myocardial infarction. Current guidelines for percutaneous coronary intervention advocate the use of distal embolic protection devices, especially in patients with large thrombus burden, undergoing percutaneous intervention for vein graft disease. This patient was treated by manual aspiration of graft thrombus using a microvena catheter and successful clot removal was achieved. There are yet no best available therapeutic options for patients undergoing percutaneous coronary intervention of saphenous vein graft lesions.     

联合抽吸导管内注射替罗非班治疗急性ST段抬高型心肌梗死临床研究

目的探讨急性sT段抬高心肌梗死（STEMI）急诊经皮冠状动脉介入治疗（PCI）中联合应用血栓抽吸导管和替罗非班经抽吸导管内注射对心肌组织灌注及临床预后的影响。方法106例急诊PCI治疗的STEMI患者根据治疗情况分为血栓抽吸＋替罗非班组（52例）和单独血栓抽吸组（54例）,比较两组患者手术后即刻梗死相关动脉的心肌梗死溶栓（TIMI）血流、TIMI心肌灌注分级（TMP）。随访30d,比较两组左心室射血分数（LVEF）、住院期间主要心脏不良事件和出血并发症发生率。结果两组基线资料比较差异无统计学意义。术前、术后两组TIMI血流,术前两组TMP差异无统计学意义（P〉0．05）。术后血栓抽吸＋替罗非班组TMP3级率较单独抽吸组明显高（76．2比68．5,P〈0．05）。两组30d随访主要心脏不良事件、LVEF、出血并发症比较差异无统计学意义（P〉0．05）。结论在STEMI急诊PCI中联合使用血栓抽吸导管和抽吸导管内注射替罗非班安全可行,可有效改善心肌组织灌注,且不增加主要心脏不良事件的发生率。     

What is the optimal reperfusion strategy for elderly patients with acute MI?

The overview of the Fibrinolytic Therapy Trialists' (FTT) Collaborative Group showed that, in more than 3000 elderly patients, thrombolytic treatment is effective in reducing mortality of patients with acute myocardial infarction with ST elevation within 12 hours from the onset of symptoms. Small-scale clinical trials confirmed the superiority of primary percutaneous coronary intervention even in older patients. However, clinical practice largely differs from the setting of clinical trials and, specifically, with respect to primary percutaneous coronary intervention. As a consequence, the results observed with percutaneous coronary intervention in "real world" patients seem to be less favorable than those obtained in trials. For this reason, reperfusion therapy with fibrinolytic agents remains the first choice of therapy for ST elevation myocardial infarction in the majority of hospitals where direct percutaneous coronary intervention facilities are not available.     

Aspiration of embolized thrombus during primary percutaneous coronary intervention

During percutaneous coronary intervention for acute myocardial infarction, distal embolization of thrombus and plaque material often occurs, despite the use of thrombectomy and aspiration catheters. Large embolized thrombi can cause occlusion of distal coronary vessels for which angioplasty most often leads to no more than poor results. We describe the successful use of an aspiration catheter to treat distally embolized thrombus, to optimize coronary reperfusion therapy, and to improve salvage of myocardial tissue. We discuss the manifestation and incidence of distal embolization and show its clinical relevance. © 2009 Wiley‐Liss, Inc.     

Combined mechanical and pharmacological approach to a thrombus‐containing lesion

Distal embolization during primary percutaneous coronary intervention for acute myocardial infarction is associated with impaired myocardial perfusion and poor outcome. Numerous pharmacological and mechanical strategies have been proposed to prevent and treat distal embolization. A successful combined mechanical and pharmacological approach to a large thrombus‐containing lesion in patients with acute coronary syndrome is described. A review of the current literature regarding the drugs and devices available for the prevention and treatment of large thrombus burden has also been performed. © 2010 Wiley‐Liss, Inc.     

Thrombus aspiration in acute myocardial infarction:Rationale and indication

Reperfusion of myocardial tissue is the main goal of primary percutaneous coronary intervention(PPCI) with stent implantation in the treatment of acute ST-segment elevation myocardial infarction(STEMI). Although PPCI has contributed to a dramatic reduction in cardiovascular mortality over three decades, normal myocardial perfusion is not restored in approximately one-third of these patients. Several mechanisms may contribute to myocardial reperfusion failure, in particular distal embolization of the thrombus and plaque fragments. In fact, this is a possible complication during PPCI, resulting in microvascular obstruction and no-reflow phenomenon. The presence of a visible thrombus at the time of PPCI in patients with STEMI is associated with poor procedural and clinical outcomes. Aspiration thrombectomy during PPCI has been proposed to prevent embolization in order to improve these outcomes. In fact, the most recent guidelines suggest the routine use of manual aspiration thrombectomy during PPCI(class Ⅱa) to reduce the risk of distal embolization. Even though numerous international studies have been reported, there are conflicting results on the clinical impact of aspiration thrombectomy during PPCI. In particular, data on long-term clinical outcomes are still inconsistent. In this review, we have carefully analyzed literature data on thrombectomy during PPCI, taking into account the most recent studies and meta-analyses.     

血栓抽吸对急性心肌梗死患者心室重构及预后的影响

目的探讨急性心肌梗死（AMI）患者直接经皮冠状动脉内介入治疗（PCI）中,应用血栓抽吸导管进行血栓抽吸对心室重构及临床预后的影响。方法选择2010年1月至2011年9月在我院心内科住院并诊断为急性sT段抬高心肌梗死（srEMI）患者270例,随机（抛硬币法）分为对照组（常规PCI组）140例及血栓抽吸组130例。检测患者直接PCI后心肌灌注指标包括术后2hST段回落（STR）和TIMI心肌灌注分级（TMPG）。所有患者均于术后5-7d及出院6个月后行超声心动图测定左室舒张末期内径（LVEDd）、左室舒张末期容积（LVEDV）、左室收缩末期容积（LVEsv）及左室射血分数（LVEF）,比较两组患者术后心肌灌注及心室重构指标的差异。对患者随访12个月,动态追踪观察两组患者随访期内心血管不良事件（MACE）的发生情况。结果血栓抽吸组STEMI患者直接PCI术后STR比例及TMPG良好比例均显著高于对照组（64．6％比45．0％,70．0％比48．6％,P〈0．01）。出院6个月后,血栓抽吸组患者LVEDd、LVEDV、LVESV显著小于对照组,而LVEF则高于对照组[（54．53±2．73）比（56．79±2．46,（118．74±4．34）比（121．23±3．52）,（58．44±3．79）比（61．94±3．83）,（49．62±3．32）比（48．12±2．15）,P〈0．05]。术后随访12个月,Kaplan—Meier生存分析发现,血栓抽吸组患者累积无MACE事件生存率显著高于对照组,差异有统计学意义（92．3％比82．3％,Logrank=4．187,P=0．041）。结论对STEMI患者急诊介入治疗中先应用血栓抽吸导管进行血栓抽吸再行PCI,可以显著改善患者心肌灌注水平,减轻术后左心室重构,并改善患者的临床预后。     

The role of distal myocardial protection devices during percutaneous coronary interventions

Opinion statement The success of intervention and clinical outcome is markedly reduced in patients who sustain distal embolization during percutaneous coronary intervention (PCI). Such embolization occurs in up to 15% of patients with acute myocardial infarction (AMI) undergoing PCI, and angiographic indicators of embolization are highly predictive of clinical and functional outcome. Saphenous vein graft (SVG) interventions carry a 20% risk of major adverse cardiac events (MACE), predominantly AMI, and significant risk of no-reflow. There are four types of embolic protection: distal occlusion/aspiration systems, filters, proximal occlusion/aspiration devices, and thrombectomy catheters. There seem to be no data to suggest that routine use of any embolic protection system is beneficial in patients with ST-elevation myocardial infarction (STEMI) undergoing PCI. The message from both the EMERALD and PROMISE trials is that embolic protection does not improve perfusion in the setting of AMI. Although pretreatment with thrombus aspiration before PCI improves angiographic reperfusion rates compared with standard PCI, enzymatic release and early clinical outcomes are not improved. Although the clinical implications of routine thrombus aspiration have yet to be established, selective use may be justified in patients with the highest thrombus burden. In addition, it should be considered in those with acute stent thrombosis and elective use of filter-based protection considered in very high risk vessel PCI (eg, last remaining conduit). There is no easy way to anticipate which SVG intervention will result in embolization. In SVG intervention, both balloon occlusion/aspiration and filter-based distal protection devices have significantly reduced the incidence of 30-day MACE, driven by AMI and should, I believe, be used routinely. Risk of complications is low with all the established devices. The profile and deliverability are continuing to improve with newer devices. Cost-effectiveness of selective use in high-risk graft cases has only recently been demonstrated.     

血栓抽吸联合冠脉内给予法舒地尔对急性心肌梗死急诊PCI后无复流的影响

目的评价急诊经皮冠脉介入治疗（PCI）中应用血栓抽吸联合冠脉内给予法舒地尔对急性心肌梗死无复流的影响、疗效及安全性。方法选择2011年7月至2012年12月我科收治的急性sT段抬高心肌梗死行急诊PCI,梗死相关动脉（IRA）术前TIMI〈1级的患者160例,随机分为观察组和对照组各80例。两组患者手术方法相同,出现无复流现象后分别经冠脉给予法舒地尔和硝酸甘油。观察两组注射药物后TIMI血流分级、TMPG分级、心电图sT段回落、左室射血分数、左室舒张末期内径及住院期间的主要心血管事件。结果观察组TIMI血流分级、TMPG分级、心电图sT段回落、左室射血分数均高于对照组（P〈0．05）,观察组左室舒张末期内径及住院期间的MACE发生率低于对照组（P〈O．05）。结论AMI行急诊PCI血栓抽吸联合冠脉内给予法舒地尔可改善冠脉血流和梗死区的心肌再灌注,改善近期预后,是安全有效的。     

优化急性ST段抬高型心肌梗死的直接经皮冠状动脉介入治疗

对ST段抬高型心肌梗死实施直接经皮冠状动脉介入治疗不应只是为获得TIMI 3级血流,而应是良好的心肌灌注。可通过上游使用血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂、他汀类调脂药,个体化正确使用血栓抽吸装置,必要时延迟支架植入等手段,优化直接经皮冠状动脉介入治疗术的效果。     

血栓抽吸术改善急性心肌梗死心肌再灌注的临床研究

目的探讨冠状动脉内血栓抽吸并联合球囊成型及支架置入术治疗急性心肌梗死（AMI）对梗死心肌再灌注的影响。方法进行急诊PCI的AMI患者共156例,对其中78例进行冠状动脉内血栓抽吸,然后进行球囊扩张及支架置入治疗。术后造影观察冠状动脉扩张效果及梗死相关血管血流及心肌灌注、心电图STR情况。结果抽吸血栓组与同期入选未抽吸组相比,TIMI血流3级分别为89％和78％;TMP灌注3级分别为88％和45％,STR〉50％者分别为68％和50％。结论经导管进行冠状动脉内血栓抽吸是治疗急性心肌梗死简单有效的方法,并可提高经皮冠状动脉介入治疗的成功率,减少无再流等并发症的发生。     

Akutversorgung des akuten Myokardinfarktes

Progress in interventional cardiology and pharmacotherapy has improved the outcome of acute myocardial infarction in recent decades. Nevertheless, acute myocardial infarction is still one of the most common causes of death in Europe. The key to successful treatment is early diagnosis. The treatment of choice for restoration of perfusion of the ischemic myocardium is primary percutaneous coronary intervention (PCI). Due to the large number of catheter laboratories distributed all over the country, this treatment should be available for nearly all patients in Germany. Bivalirudin is recommended for peri-interventional anticoagulation. If sufficient expertise is available a radial artery access is advantageous due to a significant reduction in bleeding complications. For reduction of the no-reflow phenomenon, thrombus aspiration should always be considered before stent implantation. In the absence of contraindications for a prolonged dual antiplatelet therapy, the use of drug-eluting stents is recommended. Dual antiplatelet therapy with acetylsalicylic acid and one of the new adenosine diphosphate (ADP) receptor blockers prasugrel or ticagrelor should be standard.     

急性ST段抬高性心肌梗死介入术中冠状动脉内血栓治疗进展

急性ST段抬高性心肌梗死介入治疗风险极高,其高负荷血栓常导致无复流或慢复流现象发生,如何处理冠状动脉内血栓,有效改善心肌灌注,是急需解决的问题,本文就目前针对急性ST段抬高性心肌梗死介入术中冠状动脉内血栓的治疗进展做一综述.     

血栓抽吸联合替罗非班在急诊冠状动脉介入治疗中的应用

目的:观察血栓抽吸导管联合冠状动脉内注射替罗非班对急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(PCI)中的疗效及安全性.方法:选择符合条件的AMI患者340例,均行急诊PCI,PCI术中应用血栓抽吸联合冠状动脉内注射替罗非班的180例患者作为观察组,直接行PCI的160例患者作为对照组,观察2组术后冠状动脉血流灌注水平(TIMI分级)、心肌灌注水平(TMP分级),无复流或慢血流发生率,住院期间再梗死、梗死相关血管再次血运重建、心力衰竭发生率、30 d内的死亡率、出血等并发症发生率.结果:观察组在术后冠状动脉血流灌注水平、心肌灌注水平均较对照组升高,而无复流或慢血流发生率则明显减少;观察组在住院期间再梗死、目标血管再次血运重建、心力衰竭发生率、30 d内的死亡率等方面,与对照组比较差异有统计学意义(P＜0.05).2组在出血等并发症发生率方面比较,差异无统计学意义(P＞0.05).结论:AMI患者行急诊PCI过程中,应用血栓抽吸导管联合冠状动脉内注射替罗非班可明显减少慢血流、无复流等并发症的发生,从而降低病死率,改善近期预后,是一种安全有效的治疗方法.     

急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗后心肌灌注不良的影响因素

目的:探讨急性ST段抬高心肌梗死(心梗)(STEMI)急诊经皮冠状动脉介入治疗(PCI)后心肌灌注不良的影响因素。方法:根据PCI后心肌梗死溶栓治疗(TIMI)心肌灌注分级(TMPG),91例患者分为心肌灌注不良组(TMPG0～2级,n=30)和心肌灌注正常组(TMPG3级,n=61),比较2组基本临床资料和造影结果以及介入结果,并对各因素进行Logistio回归分析,总结急性心梗急诊PCI后心肌灌注不良的影响因素。结果:91例患者中男76例,女15例,年龄38～84(62.3±11.8)岁,心肌灌注不良组合并高血压病的比例更高(80.0%比54.1%,P=0.0163),心梗部位以非前壁心梗居多(70.0%比29.5%,P=0.002);造影结果中,心肌灌注不良组梗死相关血管以右冠状动脉(RCA)更多见(63.3%比18.0%,P     

抽吸导管在急性心肌梗塞患者急诊经皮冠脉介入治疗中的应用

目的:通过抽吸导管在急性心肌梗塞患者急诊经皮冠脉介入(PCI)治疗中的应用,以评价其可行性及有效性。方法:选择30例急性ST段抬高型心肌梗塞行急诊PCI术的病人,分为两组,各15例,抽吸导管组:予抽吸导管抽吸后,根据血栓负荷情况,决定是即时支架植入,还是择期支架植入术;直接PCI组,予单纯球囊扩张后,植入支架。比较两组术后即刻TIMI血流的分级,并比较两组术前、术后2h肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、肌钙蛋白T(cTnT)定量、高敏C反应蛋白(hs-CRP)、B型脑利钠肽(BNP)、D-二聚体(D-dimer)定量的峰值。结果:抽吸导管组有13例行导管抽吸后行支架植入术,TIMI血流达到TIMI2～3级水平,只有2例出现无复流现象;直接PCI组中有8例病人支架植入后出现无复流现象(P0.05);两组病人术前CK、CK-MB、cTnT、hs-CRP、D-dimerl比较无统计学差异(P0.05)。术后,抽吸导管组的下述参数较直接PCI组显著减少,术后2h的峰值比:CK(2152.71±297.84):(3550.93±566.54)IU/I,P0.05;CK-MB(203.85±23.06):(322.85±46.01)IU/L,P0.05;cTnT(4.46±0.93):(7.71±1.19)ng/ml,P0.05;hs-CRP(7.25±1.06):(15.27±3.22)mg/L,P0.05;BNP(1441.75±321.83):(4589.75±1388.7)pg/ml,P0.05;D-dimer(134.53±40.15):(245.43±50.15)ng/ml,P0.05。结论:在急性心肌梗塞急诊PCI术中应用DiverCE抽吸导管行血栓抽吸术,可以减少急性心肌梗塞病人无复流的发生率,提高支架植入术的可靠性及安全性,是有效、安全的。     

A pilot study with a new, rapid-exchange, thrombus-aspirating device in patients with thrombus-containing lesions: the Diver C.E. study.

BACKGROUND: In patients with acute coronary syndromes (ACS), distal embolization of thrombotic material is more likely to play a key role in the pathogenesis of myocardial no-reflow during percutaneous coronary intervention (PCI). Thus, interventional techniques able to reduce thrombus burden at the culprit vessel might improve final myocardial reperfusion. OBJECTIVE: To evaluate a new rapid-exchange thrombus-aspirating catheter, the Diver C.E., in patients with thrombotic coronary lesions undergoing PCI. METHODS: Fifty patients with acute myocardial infarction (n = 44) or with non-ST-elevation ACS and angiographic evidence of coronary thrombus (n = 6) undergoing urgent PCI were prospectively enrolled. The Diver C.E. was used to aspirate coronary thrombus from the culprit lesion after placement of the guidewire. Adjunctive balloon inflations and stent implantation were used to achieve good angiographic result. Angiographic coronary flow (by means of TIMI score and corrected TIMI frame count, cTFC), thrombus score (TS), and myocardial perfusion (by means of postintervention myocardial blush grade, MBG) were assessed in all patients. RESULTS: The device could be successfully employed in 96% of the cases (48/50) and yielded significant (P < 0.0001) acute reduction in thrombus burden (TS: predevice 3.5 +/- 0.8, postdevice 2.5 +/- 0.9) and improvement in coronary flow (TIMI grade: predevice 1.0 +/- 0.9, postdevice 2.0 +/- 0.9; CTFC predevice 71 +/- 31, postdevice 39 +/- 26). Final TIMI grade 0-1 was observed in one patient only (2%). A significant (P = 0.02) correlation was found between preintervention TS and efficacy of thrombus aspiration. A more pronounced acute reduction of thrombus burden after thrombus aspiration (TS reduction > or = 2) was associated with a better postintervention angiographic myocardial perfusion (MBG 2.3 +/- 0.9 vs 1.7 +/- 0.8; P = 0.05). CONCLUSIONS: This new, easy-to-use, device is able to reduce thrombus burden and to improve coronary flow in patients with thrombus-containing lesions. The improvement in myocardial perfusion associated to greater thrombus removal highlights the importance of thrombus aspiration in the management of thrombus-burdened coronary lesions.