Association of Physician Variation in Use of Manual Aspiration Thrombectomy With Outcomes Following Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Abstract

IMPORTANCE Following negative randomized clinical trials, US guidelines downgraded support for routine manual aspiration thrombectomy (AT) during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). However, some PCI operators continue to endorse a clinical benefit with AT use despite the lack of supportive data. OBJECTIVE To examine temporal trends and comparative outcomes of AT use during pPCI for STEMI. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of the National Cardiovascular Data Registry (NCDR) CathPCI Registry from July 1, 2009, to June 30, 2016, to assess temporal trends and in-hospital outcomes associated with AT use. To evaluate outcomes through 180 days, a subanalysis was conducted among Centers for Medicare and Medicaid Services-linked patients from July 1, 2009, through December 31, 2014. The comparative effectiveness analysis was performed using instrumental variable analyses to account for treatment selection bias. The instrumental variable was operator's preference to use AT during pPCI. Data were analyzed between February 1, 2017, and April 1, 2018. EXPOSURES Aspiration thrombectomy use during pPCI for STEMI. MAIN OUTCOMES AND MEASURES Primary outcomes included in-hospital stroke and death. Secondary outcomes included heart failure, stroke, all-cause rehospitalization, and death through 180 days of follow-up. RESULTS Among all pPCIs performed (683 584), the mean (SD) age of patients was 61.7 (12.8) years, 489 257 were male (71.6%), and 596 384 were white (87.2%). Among patients undergoing pPCI, AT use increased from 2009 through 2011, with peak use of 13.8%. This was followed by a decline of more than 9%, reaching 4.7% by mid-2016. Overall, AT was used in 10.8% of pPCIs (lowest operator group median, 0%; highest operator group median, 33.8%). After instrumental variable analysis, AT use was associated with no difference in in-hospital death (adjusted absolute risk difference, −0.18%; 95% CI, −0.53% to 0.16%; P = .29) and a small increase in in-hospital stroke (adjusted RD, 0.14%; 95% CI, 0.01%-0.30%; P = .03). Among Centers for Medicare and Medicaid Services-linked patients, AT use was not associated with differences in death, heart failure, stroke, or rehospitalization at 180 days. CONCLUSIONS AND RELEVANCE In this large, nationwide analysis, AT use during STEMI pPCI declined by more than 50% since 2011, with use as of mid-2016 at less than 5%. Selective AT use was associated with a small excess risk of in-hospital stroke and no difference in other outcomes through 180 days of follow-up.

Aspiration thrombectomy in ST-Elevation myocardial infarction: Further insights from a network meta-analysis of randomized trials

“…Review of the United States National Cardiovascular Data Registry (NCDR) CathPCI Registry by Secemsky et al shows that the uptake of AT has appropriately been low in the recent past. 33 …”

Health Care Utilization Following Inpatient Femoropopliteal Revascularization With Drug-Coated Balloon Angioplasty: A Nationwide Cohort Analysis

“…Balancing properties were assessed using standardized differences and balance plots. As previously suggested, 12 a standardized difference of ≥0.1 was considered a meaningful imbalance in the covariates. Standard errors of the propensity score matching analysis were not adjusted for clustering by hospitals.…”

Multicenter and all‐comers validation of a score to select patients for manual thrombectomy, the DDTA score

“…MT use has decreased progressively since 2016 despite the progressive increase in P-PCI. 4,5,28 This is not surprising but it could also underscore that MT is being avoided in excess. For example, the meta-analysis performed by the Thrombectomy Trialists Collaboration reported that there were no significant differences in recurrent myocardial infarction, stent thrombosis, heart failure, or target vessel revascularization in patients treated with MT but patients with high thrombus burden MT was associated with fewer cardiovascular deaths (HR: 0.80; 95% CI 0.65-0.98; p = .03).…”

“…MT use has decreased progressively since 2016 despite the progressive increase in P‐PCI 4,5,28 . This is not surprising but it could also underscore that MT is being avoided in excess.…”

“…MT use has declined progressively since these recommendations were published 3‐5 although clinical registries reflect that it is still used in 10–30% of primary percutaneous coronary interventions (P‐PCI) based to operators criteria 6‐10 . Under the premises of the unmet need of uniform and standardized tools for decision‐making on MT, we designed a simple scale to estimate the probability of successful MT in P‐PCI: the DDTA score 11 .…”