The Rise and Fall of Routine Manual Thrombectomy for ST-Elevation Myocardial Infarction

Manual thrombectomy (MT) with an aspiration catheter is frequently used in primary percutaneous coronary intervention (PPCI) for acute myocardial infarction with ST-segment elevation (STEMI). It is used to reduce the thrombus burden and the risk of no-reflow in the infarct related artery. This article summarises a chronological overview of the available evidence for its routine use in PPCI. An early series of small randomised controlled trials (RCTs) have shown a benefit of PPCI with MT over percutaneous coronary intervention alone, mainly when considering intermediate endpoints reflecting myocardial reperfusion. However, a recent series of large multicentre RCTs failed to corroborate the initial enthusiasm for MT, showing no improved benefit on hard endpoints such as mortality when compared with PPCI without MT. Furthermore, the largest RCT to date raised safety concerns after reporting an increased stroke risk after MT. We review the background, value, and implications of the current evidence before concluding that the routine use of MT in PPCI for STEMI should not be encouraged.