Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction

Abstract

This randomized trial compared rheolytic thrombectomy before direct infarct artery stenting with direct infarct artery stenting alone in 100 patients with a first acute myocardial infarction (AMI). The primary end point of the study was early ST-segment elevation resolution, and the secondary end points were corrected Thrombolysis In Myocardial Infarction (TIMI) frame count, infarct size, and 1-month clinical outcome. The primary end point rates were 90% in the thrombectomy group and 72% in the placebo group (p ‫؍‬ 0.022). Randomization to thrombectomy was independently related to the primary end point (odds ratio 3.56, p ‫؍‬ 0.032). M acro-and microembolization during percutaneous coronary intervention (PCI) is frequent and may result in the obstruction of the microvessel coronary network. 1 In the setting of acute myocardial infarction (AMI), PCI-related embolization results in a decreased efficacy of mechanical reperfusion and myocardial salvage. Direct stenting without predilation may decrease embolization and the incidence of the no-reflow phenomenon. 2,3 More specific approaches to the problem of microvessel embolization during PCI include thrombectomy by different techniques and the use of anti-embolic protection devices. One randomized trial has reported rheolytic thrombectomy to be effective in decreasing embolization in patients who underwent PCI on venous grafts or native coronary vessel with massive thrombosis 4 ; however, few data exist on the effectiveness of rheolytic thrombectomy in the setting of AMI. 5,6 This randomized trial assessed the efficacy of rheolytic thrombectomy before direct infarct artery stent implantation in patients who underwent PCI for AMI.• • • Criteria for enrollment included chest pain persisting Ͼ30 minutes associated with an ST-segment elevation of Ն0.1 mV in Ն2 contiguous electrocardiographic leads. The exclusion criteria included (1) previous myocardial infarction, (2) administration of fibrinolytic therapy, (3) bundle branch block or ventricular pacing on the baseline electrocardiogram preventing analysis of the ST-segment changes, (4) infarct-related artery (IRA) diameter Ͻ2.5 mm on visual angiographic assessment, and (5) inability to obtain informed consent. Patients with cardiogenic shock due to predominant ventricular failure were included, as were patients with high-risk coronary anatomy. After coronary angiography, eligible patients were randomly assigned to direct IRA stenting alone or thrombectomy before stenting. Computer-generated sequences and assignments using a closed envelope system were used to perform randomization. Thrombectomy was accomplished with the second-generation rheolytic thrombectomy 4Fr catheter (AngioJet, Possis Medical, Minneapolis, Minnesota). Two types of stents were used: a tubular closed-cell carbon-coated stent (Techno, Sorin, Saluggia, Italy) and a tubular open-cell stent (Zeta, Guidant, Santa Clara, California). All patients received abciximab (ReoPro, Centocor, Malvern, Pennsylvania), if not contraindicated, immediately before the ...

The Coronary Circulation as a Target of Cardioprotection

“…208 Also, no reduction of microvascular obstruction and infarct size was found with MRI. [209][210][211] Hyperoxemia, 212,213 aspiration or mechanical thrombectomy, [214][215][216][217][218][219][220][221] and intra-aortic balloon counterpulsation 222 did not reduce infarct size or improve coronary blood flow. More recently, also the cardioprotection by cyclosporine A which had been shown in a small-scale proof-of-concept trial 223 was not confirmed in another smaller study with prethrombolytic cyclosporine A 224 and, importantly, not in 2 larger-scale phase III trials, Does Cyclosporine Improve Clinical Outcome in ST Elevation Myocardial Infarction Patients (CIRCUS) and CyclosporinE A in Reperfused Myocardial Infarct (CYCLE).…”

Thrombus Aspiration Therapy and Coronary Thrombus Components in Patients with Acute ST-Elevation Myocardial Infarction

“…In this regard, the use of a mechanical device for thrombus removal or trapping to improve clinical outcomes after p-PCI is attractive, and the efficacy of these devices has been tested in many clinical trials. Although some data, especially those regarding the use of distal protection devices, have failed to show clinical benefits due in part to patient and device selection [48][49][50][51][52][53] , many recent large-scale randomized trials have demonstrated significant improvements in myocardial perfusion 45,[54][55][56][57][58][59][60][61][62][63][64][65][66][67] and the left ventricular function 64,65) in addition to reduced mortality 68) ( 69) . In addition, Burzotta et 70) .…”

Adjunctive Thrombectomy for Acute Myocardial Infarction

“…16 Angiographically visible thrombus was required in 5 trials. 13,24,32,33,35 Patients in shock or those requiring intra-aortic balloon counterpulsation or mechanical ventilation were excluded from 11 trials, 13,15,16,18,20,24,26,29,31,34,35 and patients with previous coronary artery bypass were excluded from 9 trials. 12,14,16,18,20,24,28,34,35 Only 2 RCTs specifically excluded patients with a left ventricular ejection fraction Ͻ30%.…”