Protection Devices and Thrombectomy for Native Coronary Artery STEMI
Protection Devices and Thrombectomy for Native Coronary Artery STEMI
Distal thrombus embolization during primary percutaneous coronary intervention occurs frequently and is associated with compromised long term outcomes. Apart from pharmacological agents, great interest has recently been shown in various mechanical devices aimed at either reducing the amount of thrombus present or preventing its distal migration. However, despite the intuitive appeal of such devices, their application remains uncertain given the results of emerging randomized trials. Data presently available show a significant discrepancy between softer clinical endpoints such as reperfusion markers and hard clinical outcomes. The purpose of this review is to summarize the current clinical evidence and provide guidelines for their use.
Primary percutaneous coronary intervention (PCI) is established as optimal therapy for patients with ST-elevation myocardial infarction (STEMI). The goal of primary PCI is to achieve a thrombolysis in myocardial infarction (TIMI) 3 flow and also to restore adequate perfusion at the myocardial level. However, visible thrombus embolization to the distal circulation during primary PCI occurs in up to 14% of patients, and outcomes in these patients are compromised. Furthermore, even in patients without such macroembolization, myocardial reperfusion is often suboptimal, with patients showing persistent ST-segment elevation and abnormal myocardial blush grades (MBG). The wellrecognized "slow/no reflow" phenomenon results when there is failure to achieve myocardial reperfusion despite the presence of a patent epicardial coronary artery, and this too has been associated with adverse long-term outcomes. Subsequently, great interest has been shown in various techniques aimed at either reducing the amount of thrombus present or preventing its distal migration.
Apart from pharmacological agents such as glycoprotein (GP) IIb/IIIa antagonists, several mechanical devices have been proposed to prevent distal embolization. These can be divided into: 1) distal embolic filters; 2) occlusive devices: (a) proximal or (b) distal; 3) intracoronary aspiration thrombectomy; 4) thrombectomy with the X-Sizer system (ev3, Inc., Plymouth, Minnesota); and 5) laser debulking. However, despite their intuitive appeal, their application remains uncertain given the results of emerging randomized trials. The purpose of this review is to summarize the current clinical evidence and provide guidelines for their use.
Distal thrombus embolization during primary percutaneous coronary intervention occurs frequently and is associated with compromised long term outcomes. Apart from pharmacological agents, great interest has recently been shown in various mechanical devices aimed at either reducing the amount of thrombus present or preventing its distal migration. However, despite the intuitive appeal of such devices, their application remains uncertain given the results of emerging randomized trials. Data presently available show a significant discrepancy between softer clinical endpoints such as reperfusion markers and hard clinical outcomes. The purpose of this review is to summarize the current clinical evidence and provide guidelines for their use.
Primary percutaneous coronary intervention (PCI) is established as optimal therapy for patients with ST-elevation myocardial infarction (STEMI). The goal of primary PCI is to achieve a thrombolysis in myocardial infarction (TIMI) 3 flow and also to restore adequate perfusion at the myocardial level. However, visible thrombus embolization to the distal circulation during primary PCI occurs in up to 14% of patients, and outcomes in these patients are compromised. Furthermore, even in patients without such macroembolization, myocardial reperfusion is often suboptimal, with patients showing persistent ST-segment elevation and abnormal myocardial blush grades (MBG). The wellrecognized "slow/no reflow" phenomenon results when there is failure to achieve myocardial reperfusion despite the presence of a patent epicardial coronary artery, and this too has been associated with adverse long-term outcomes. Subsequently, great interest has been shown in various techniques aimed at either reducing the amount of thrombus present or preventing its distal migration.
Apart from pharmacological agents such as glycoprotein (GP) IIb/IIIa antagonists, several mechanical devices have been proposed to prevent distal embolization. These can be divided into: 1) distal embolic filters; 2) occlusive devices: (a) proximal or (b) distal; 3) intracoronary aspiration thrombectomy; 4) thrombectomy with the X-Sizer system (ev3, Inc., Plymouth, Minnesota); and 5) laser debulking. However, despite their intuitive appeal, their application remains uncertain given the results of emerging randomized trials. The purpose of this review is to summarize the current clinical evidence and provide guidelines for their use.
