Routine thrombus aspiration in STEMI did not reduce death, reinfarction, or heart failure, with increased stroke risk (HR 2.06) compared to PCI alone.
Do thrombus clearance strategies improve clinical outcomes in patients with STEMI undergoing primary PCI?
Evidence overwhelmingly argues against routine manual thrombus aspiration in STEMI due to lack of efficacy and increased stroke risk, supporting only selective bailout use in carefully chosen patients.
Absolute Event Rate: 0% vs 0%
Thrombus burden in patients with ST-segment elevation myocardial infarction (STEMI) facilitates distal embolization and microvascular obstruction (MVO), jeopardizing tissue reperfusion despite an open epicardial artery. Early single-center randomized trials (Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS), Thrombectomy With Export Catheter in Infarct-Related Artery During Primary Percutaneous Coronary Intervention (EXPIRA)) have exhibited improved microvascular surrogates and suggested clinical benefit; however, pragmatic multicenter trials did not confirm efficacy for a routine aspiration strategy, i.e., Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) and Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI (TOTAL) did not demonstrate a reduction in death, reinfarction, or heart failure with aspiration plus percutaneous coronary intervention (PCI) versus PCI alone. In TOTAL, routine aspiration intake increased stroke: 0.7% versus 0.3% at 30 days (hazard ratio (HR) 2.06; 95% confidence interval (CI) 1.13–3.75), while the excess was evident within 48 hours and the signal was sustained to 180 days (1.0% versus 0.5%, HR 2.00, 95% CI 1.25–3.20); meanwhile, disabling or fatal strokes were also more frequent (HR 2.69). Accordingly, the current European Society of Cardiology (ESC) 2023 and American College of Cardiology/American Heart Association (ACC/AHA) 2025 guidelines dissuade routine manual aspiration (Class III, Level A) while supporting selective bailout application when large residual thrombus or refractory no-reflow exists despite standard measures. Device-based alternatives (rheolytic thrombectomy, distal protection) have failed to improve hard outcomes in native vessel primary PCI; meanwhile, newer continuous aspiration and coronary stent-retriever systems remain practical but unproven in outcomes trials. This narrative review appraises randomized and mechanistic evidence and proposes a practical, safety-first algorithm. This approach includes performing primary PCI rapidly with guideline-directed antithrombotic therapy; considering thrombectomy only in rare cases of very large thrombus burden when it is likely to improve flow; if aspiration is utilized, careful purging must be ensured to prevent air embolism, continuous negative pressure must be maintained, and a single slow pass performed with sustained suction to minimize embolization. Currently, in practice, the evidence overwhelmingly argues against routine aspiration. However, a selective and technically disciplined bailout approach may still be warranted in carefully chosen patients.
Marek null Tomala (Fri,) reported a other. Routine thrombus aspiration in STEMI did not reduce death, reinfarction, or heart failure, with increased stroke risk (HR 2.06) compared to PCI alone.