Is it possible to predict which patients need distal protection during primary angioplasty?

A commentary on the manuscript by Celik entitled “Distal embolus protection during primary percutaneous coronary intervention: Lessons learned from the clinical trials”

“…It is no wonder that the DP device should not be used for all patients with acute myocardial infarction in a clinical practice but for patients at a high risk of distal embolization and/or no-reflow; thus, it should be identified which patients need the DP device during primary PCI. The present study suggests that, in patients with culprit lesions located on the right coronary artery, large thrombus burden, or large infarct-related artery, the use of a DP device during primary PCI resulted in a higher rate of patients achieving optimal reperfusion and smaller infarct size, possibly due to a reduced risk of thrombotic procedural complications [2]. However, the benefit of a DP device was not shown in other clinical or angiographic variables, such as gender, age, diabetes, hypercholesterolemia, prior infarction, preinfarction angina, pain onset to PCI time, left ventricular ejection fraction, left anterior descending artery, multivessel coronary disease, preprocedural TIMI flow grade, calcification, bifurcation, stent length or maximal inflation pressure [2].…”

“…We thank Dr. Celik and colleagues for their interesting comments [1] on our manuscript [2]. As they pointed out, [1] the Enhanced Myocardial Efficacy and removal by Aspiration of Liberalized Debris (EMERALD) trial, [3] the randomized controlled Protection Devices in PCI Treatment of Myocardial Infarction for Salvage of Endangered Myocardium (PROMISE) study [4] and the Protection of distal Embolization in High-Risk Patients with Acute Myocardial Infarction (PREMIAR) study [5] failed to demonstrate a clear benefit of the routine use of a distal protection (DP) during primary percutaneous coronary intervention (PCI) as compared with conventional PCI strategy, whereas the analyses of several single-center trials have shown that primary PCI using DP device may result in improved surrogate markers of effective reperfusion such as corrected TIMI frame count, myocardial blush grade and STsegment resolution, left ventricular function, and clinical outcomes in comparison with either historical or concurrent controls [6][7][8][9][10][11].The major reason for the different outcomes between these single-center trials and 3 randomized trials could be ascribed to differences in populations.…”

Impact of vessel size on distal embolization, myocardial perfusion and clinical outcome in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction

“…In fact, in a recent report Umeda et al [37] observed significantly larger benefits from distal protection devices in terms of myocardial perfusion and infarct size only in larger vessels.…”

Distal embolus protection during primary percutaneous coronary intervention: Lessons learned from the clinical trials

“…They found that distal protection (DP) use was associated with higher rates of optimal reperfusion in patients with right coronary artery (RCA) lesions, thrombus score ≥ 4 or infarct-related artery (IRA) of ≥ 3.5 mm in diameter. In this population (RCA location, thrombus score ≥ 4, or IRA ≥ 3.5 mm), DP use reduced the risk of thromboembolic complications, resulting in a smaller infarct size [1].…”

“…[1] In that nicely designed study, the authors sought to identify in patients with ST-segment elevation acute myocardial infarction (STEMI) which clinical and angiographic characteristics might indicate the patients who will benefit from the use of a distal protection device. They found that distal protection (DP) use was associated with higher rates of optimal reperfusion in patients with right coronary artery (RCA) lesions, thrombus score ≥ 4 or infarct-related artery (IRA) of ≥ 3.5 mm in diameter.…”