Key result
Stent-retriever thrombectomy before PCI reduces infarct size by ~26% versus PCI alone.
Why the study?
Patients with myocardial infarction and large thrombus burden face greater infarct size and higher mortality, but no effective therapy exists for this high-risk subgroup.
Does stent-retriever thrombectomy followed by conventional PCI reduce infarct size in patients with STEMI and large thrombus burden compared to conventional PCI alone?
RCT (n=156)
Open-label
Randomly assigned
Yes
Does stent-retriever thrombectomy followed by conventional PCI reduce infarct size in patients with STEMI and large thrombus burden compared to conventional PCI alone?
Stent-retriever thrombectomy prior to conventional PCI significantly reduces infarct size in STEMI patients with large thrombus burden compared to PCI alone.
Answers are grounded in this paper and cite their sources.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Large thrombus burden remains a significant challenge in primary PCI, and there is an ongoing need for effective strategies to improve myocardial reperfusion and limit infarct size. The reduction in infarct size demonstrated in NATURE, together with the favorable safety profile observed, represents important new evidence for mechanical thrombectomy in patients with LTB.”
“The use of a stent retriever should be investigated in future trials to assess whether thrombus burden mitigation before conventional PCI reduces morbidity and mortality in patients with STEMI and a large thrombus burden.”
“NATURE asks a more useful question. Can we improve the order in which PCI is performed? The answer is not yet definitive, but the signal is provocative. Sometimes progress does not require a new finality; it requires a new first move.”
Stent-retriever thrombectomy in large-thrombus STEMI shows a provocative signal but remains unproven; prospective trials are required before any practice consideration.
Background Patients with myocardial infarction and large thrombus burden face greater infarct size and higher mortality, yet no effective therapy exists for this high-risk subgroup. Objectives To investigate the effects of stent-retriever thrombectomy in addition to conventional percutaneous coronary intervention (PCI) versus conventional PCI alone on infarct size. Methods In this open-label, multicenter, superiority trial, 160 patients with ST-segment elevation myocardial infarction and large thrombus burden at angiography (TIMI thrombus grade ≥3 in infarct-related artery) were consented and 156 randomly assigned to undergo stent-retriever thrombectomy followed by conventional PCI or conventional PCI alone. Primary outcome was infarct size extension assessed by area under the curve (AUC) for creatine kinase (CK)-MB. Safety outcome was major adverse cardiovascular events (MACE; comprising cardiovascular death, nonfatal myocardial infarction, nonfatal stroke), at 3 and 30 days. Results Infarct size (CK-MB AUC) was lower in the stent-retriever group (n=78) versus the conventional group (n=76) (3965 IU/L·h; interquartile range [IQR] 2480–5092 versus 5250; IQR 3506–7449; difference –1359, 95% CI –2231 to –522; p=0.001). At exploratory cardiac magnetic resonance findings, infarct size was lower in the stent-retriever group (n=64; left ventricle, 17%; IQR 11–28) versus the conventional PCI group (n=59; 28.0%; IQR 18–33; difference –7.0, 95% CI –12 to –2.0), whereas left ventricular volumes and ejection fraction did not differ. There was no MACE at 3 days and 1 at 30 days in the stent-retriever group versus 2 and 3, respectively, in the conventional PCI group. Conclusions Stent-retriever thrombectomy followed by conventional PCI in patients with large thrombus burden undergoing primary PCI ≤8 hours of symptom onset was associated with reduced infarct size versus conventional PCI alone.
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Valgimigli et al. (2026) conducted an RCT in ST-segment elevation myocardial infarction with large thrombus burden (n=156). Stent-retriever thrombectomy vs. Conventional PCI alone was evaluated on Infarct size extension assessed by area under the curve (AUC) for creatine kinase (CK)-MB (difference -1359, 95% CI -2231 to -522, p=0.001). Stent-retriever thrombectomy followed by conventional PCI reduced infarct size compared to conventional PCI alone.
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