What is the clinical evidence from this study?

Study design: RCT. Population: ST-segment elevation myocardial infarction (STEMI) (n=214). Intervention: Manual thrombectomy vs. PCI-alone. Primary outcome: Pre-stent thrombus burden as a percentage of segment analysed (p=0.373).

What does this research mean for the field?

Manual thrombectomy does not reduce pre-stent thrombus burden at the culprit lesion compared to percutaneous coronary intervention alone in patients with ST-segment elevation myocardial infarction. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This research investigates whether manual thrombectomy reduces thrombus burden compared to PCI alone in STEMI patients.

May 30, 2026Open Access

Culprit lesion thrombus burden after manual thrombectomy or percutaneous coronary intervention-alone in ST-segment elevation myocardial infarction: the optical coherence tomography sub-study of the TOTAL (ThrOmbecTomy versus PCI ALone) trial

Key Result

Manual thrombectomy did not significantly reduce pre-stent thrombus burden at the culprit lesion compared with PCI-alone in patients with STEMI (2.36% vs. 2.88%, P=0.373).

Key Points

This research investigates whether manual thrombectomy reduces thrombus burden compared to PCI alone in STEMI patients.
N = 10,732 in the TOTAL trial; 214 patients enrolled for OCT sub-study from 13 sites across 5 countries.
Optical coherence tomography performed after thrombectomy and PCI-alone to assess thrombus burden.
Thrombus quantification was completed by an independent core laboratory blinded to treatment.
Pre-stent thrombus burden was 2.36% in the thrombectomy group and 2.88% in the PCI-alone group (P = 0.373).
Absolute pre-stent thrombus volume showed no significant difference (2.99 vs. 3.74 mm(3), P = 0.329).
Secondary outcomes of thrombus quadrants and post-stent burden showed no differences between groups.

Study Design

Type

RCT (n=214)

Blinding

Core laboratory blinded

Randomization

Randomized

Multicenter

Yes

Structured PICO

Does manual thrombectomy reduce pre-stent thrombus burden in STEMI patients treated with primary PCI?

Population

214 STEMI patients treated with primary PCI, multinational (13 sites in 5 countries)

Intervention

Manual thrombectomy (using the Export catheter) during primary PCI

Comparator

Primary PCI alone

Outcome

Pre-stent thrombus burden as a percentage of segment analysed, measured by optical coherence tomography (OCT)surrogate

Manual thrombectomy does not significantly reduce pre-stent thrombus burden compared to PCI-alone in STEMI patients, as assessed by OCT.

Main Result

Absolute Event Rate: 2.36% vs 2.88%

p-value: p=0.373

Limitations

Observed mean pre-stent thrombus burden was lower than anticipated, potentially underpowering the study
Inability to image patients with high residual thrombus burden due to vessel re-occlusion or inability to clear blood
Passage of catheters may have displaced thrombus prior to imaging
Potential exclusion of patients with more extreme thrombus burden due to operator discretion

Abstract

AIMS: Manual thrombectomy has been proposed as a strategy to reduce thrombus burden during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, the effectiveness of manual thrombectomy in reducing thrombus burden is uncertain. In this substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial, we compared the thrombus burden at the culprit lesion using optical coherence tomography (OCT) in patients treated with thrombectomy vs. PCI-alone. METHODS AND RESULTS: The TOTAL trial (N = 10 732) was an international, multicentre, randomized trial of thrombectomy (using the Export catheter, Medtronic Cardiovascular, Santa Rosa, CA, USA) in STEMI patients treated with primary PCI. The OCT substudy prospectively enrolled 214 patients from 13 sites in 5 countries. Optical coherence tomography was performed immediately after thrombectomy or PCI-alone and then repeated after stent deployment. Thrombus quantification was performed by an independent core laboratory blinded to treatment assignment. The primary outcome of pre-stent thrombus burden as a percentage of segment analysed was 2.36% (95% CI: 1.73-3.22) in the thrombectomy group and 2.88% (95% CI: 2.12-3.90) in the PCI-alone group (P = 0.373). Absolute pre-stent thrombus volume was not different (2.99 vs. 3.74 mm(3), P = 0.329). Other secondary outcomes of pre-stent quadrants of thrombus, post-stent atherothrombotic burden, and post-stent atherothrombotic volume were not different between groups. CONCLUSION: Manual thrombectomy did not reduce pre-stent thrombus burden at the culprit lesion compared with PCI-alone. Both strategies were associated with low thrombus burden at the lesion site after the initial intervention to restore flow.

Expert Takes5 quotes

1/5

“The message from this study is that thrombectomy should not be used as a routine strategy. This is still an important therapy, but given the downsides we observed in our trial, its use should be quite selective and as a measure when an initial balloon angioplasty attempt fails to open up the artery, rather than as a routine strategy.”

Sanjit Jolly, Interventional cardiologist, McMaster UniversityMcMaster Universityauto_pipelineView source

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