Intracoronary thrombus in ST-segment elevation myocardial infarction: Practical management strategies for the interventional cardiologist

Intracoronary thrombus is a hallmark of ST-segment elevation myocardial infarction (STEMI) and remains a major challenge during primary percutaneous coronary intervention (PPCI). Large thrombus burden is associated with distal embolization, microvascular obstruction, no-reflow, stent thrombosis, and adverse clinical outcomes. Optimal management requires an individualized approach integrating pharmacological and mechanical strategies. This review summarizes the pathophysiology, angiographic assessment, and clinical implications of intracoronary thrombus in STEMI. Contemporary pharmacological therapies, including dual antiplatelet therapy, anticoagulation, glycoprotein IIb/IIIa inhibitors, and intracoronary thrombolytics, are discussed alongside mechanical approaches such as aspiration thrombectomy, mechanical thrombectomy devices, direct stenting, and deferred stenting. Current evidence from major clinical trials and guideline recommendations is reviewed to clarify the selective role of these therapies in modern practice. A practical stepwise management algorithm is proposed to assist interventional cardiologists in tailoring therapy according to thrombus burden, coronary flow, and lesion characteristics. Emerging technologies and future directions aimed at improving thrombus management and microvascular reperfusion are also highlighted. This manuscript is a narrative review of intracoronary thrombus management in acute coronary syndrome, particularly STEMI during PPCI. A structured literature search was performed in PubMed and Embase, along with major guideline documents and cardiovascular society recommendations. Studies published from 2000 to 2026 were included using keywords such as "STEMI," "intracoronary thrombus," "thrombectomy," and "no-reflow." Eligible evidence included randomized controlled trials, observational studies, meta-analyses, and guidelines, while chronic coronary syndromes and chronic total occlusion-related thrombus were excluded. No formal quality assessment or statistical synthesis was performed, and findings were synthesized qualitatively for clinical relevance.