Thrombectomy in Acute Myocardial Infarction

On Topaz, Allyne Topaz, Pritam R Polkampally
Interventional Cardiology, 2009;4(1):86-91
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Abstract

Percutaneous coronary intervention (PCI) is the preferred management strategy for ST-segment-elevation myocardial infarction (STEMI) patients. However, a significant number of revascularisations result insuboptimal restoration of epicardial antegrade flow and inadequate myocardial tissue perfusion. This is mainly attributed to the underlying thrombus burden within the infarct-related vessel. Interventions for thrombotic lesions are clearly associated with an increased risk of acute and long-term complications. Thrombus remains a predictor of ischaemic complications, immediate and late stent thrombosis, increased in-hospital complications, death at six months and recurrent MI. Two types of thrombus removal device are available for utilisation in the setting of acute MI (AMI): aspiration-based catheters and mechanical thrombectomy. Administration of either systemic or selective adjunct pharmacotherapy can be useful in conjunction with application of all thrombus removal devices. Recent studies have demonstrated that thrombus aspiration is applicable and safe in a large majority of patients with STEMI, resulting in better reperfusion and clinical outcomes than standard PCI. However, it is unclear whether these findings are a direct result of a reduction in thrombus burden, facilitation of direct stenting or a combination of the two. The heavier the underlying thrombus burden, the higher the yield of mechanical thrombectomy over aspiration catheter. The role of thrombectomy as a useful adjunct therapy aimed specifically at direct contact and clearance of AMI-related thrombus continues to evolve.
Keywords
Thrombus, thrombolysis, acute myocardial infarction (AMI), ST-segment-elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI), aspiration catheter, thrombectomy, AngioJet, laser, X-Sizer, coronary, myocardial perfusion
Disclosure On Topaz is on the speaker’s bureau of eV3, Possis/Medrad and Spectranetics. Allyne Topaz and Pritam R Polkampally have no conflicts of interest to declare. None of the authors is a stock holder or has any financial investment in any interventional cardiology industrial entity.
Received: June 30, 2009 Accepted July 22, 2009
Correspondence: On Topaz, Professor of Medicine and Pathology, and Director, Interventional Cardiology, Division of Cardiology, McGuire Veterans Affairs Medical Center, 1201 Broad Rock Blvd, Richmond, VA 23249, US. E: On.Topaz@med.va.gov

Plaque rupture and subsequent thrombus formation account for most acute myocardial infarctions (AMIs). Percutaneous coronary intervention (PCI) is considered the preferred treatment for ST-segment-elevation myocardial infarction (STEMI), for evolving non-STEMI (NSTEMI) and for rescue intervention post-thrombolytics.1 The main goals of primary and rescue PCI in AMI include restoration of a normal TIMI 3 antegrade flow, enhancement of myocardial tissue perfusion and achievement of maximal myocardial salvage. However, the reality of acute or rescue PCI for patients with STEMI is quite disturbing as many interventions fail to gain an adequate outcome. The main cause is the presence and insufficient removal of the underlying thrombus. This view is corroborated by careful examination of published data from the Clopidogrel as Adjunctive Reperfusion Therapy Thrombolysis in Myocardial Infarction (CLARITY-TIMI 28) study. Altogether, 3,491 STEMI patients treated with fibrinolytic therapy2 were enrolled. Angiography was scheduled 48–192 hours (median 84 hours after randomisation). Interestingly, a unique angiographic perfusion score (APS) representing the sum of TIMI flow grade and myocardial perfusion grade was used for assessment before and after PCI. Among 1,278 patients who underwent PCI, full perfusion, defined as an APS of 10–12, was gained in only 50%, partial perfusion (APS 4–9) was found in 47% and 3.1% had failed perfusion (APS 0–3). The optimal APS of 10–12 was associated with the lowest mortality, while partial perfusion and failed perfusion were associated with higher mortality at 30 days. Full perfusion was also associated with a lower incidence of recurrent MI, a composite of MI and death, recurrent myocardial ischemia, severe arrhythmias, congestive heart failure and shock. Thus, inevitably, during primary or rescue PCI revascularisation, thrombus, whether visible by angiography or not, frequently presents a formidable obstacle to the attainment of the above-mentioned goals.

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