Jurnal Reading Divisi

Invasive

Does Residual Thrombus After

Aspiration Thrombectomy Affect the
Outcome of Primary PCI in Patients
With ST-Segment Elevation
Myocardial Infarction ?
An Optical Coherence Tomography Study
JACC : VOL . 9 , NO . 19 , 2016

Pembimbing : DR. Dr. Zulfikri Mukhtar, SpJP(K)

Penyaji
: Dr. Syaifullah

INTRODUCTIO
N
Routine aspiration thrombectomy

failed to show
clinical benefit in patients with STEMI
Routine aspiration thrombectomy before percutaneous
coronary intervention (PCI) did not reduce the risk of
cardiovascular death, recurrent myocardial infarction, cardiogenic
shock, or NYHA FC IV heart failure within 180 days (TOTAL trial)
Intracoronary optical coherence tomography (OCT)
accurately evaluate plaque morphologies, such as thin-cap
fibroatheroma, macrophages, and intracoronary thrombus
TOTAL substudy using OCT manual aspiration
thrombectomy did not reduce prestent thrombus burden
at the culprit lesion compared with PCI alone

Routine aspiration thrombectomy before percutaneous

coronary intervention (PCI) did not reduce the risk of
cardiovascular death, recurrent myocardial infarction, cardiogenic
shock, or NYHA FC IV heart failure within 180 days (TOTAL trial)

Ineffective Removal of
Thrombus ?

Intracoronary optical coherence tomography (OCT)

accurately evaluate plaque morphologies, such as thin-cap
fibroatheroma, macrophages, and intracoronary thrombus
TOTAL substudy using OCT manual aspiration
thrombectomy did not reduce prestent thrombus burden
at the culprit lesion compared with PCI alone

AIM OF
STUDY

To test if residual thrombus burden after

thrombectomy affects the outcomes of
primary PCI in patients with STEMI

METHODS

Patients characeristics :
Inclusion : Patients admitted to Hirosaki University
Hospital (Hirosaki, Japan) with STEMI between January
2013 and June 2014
Exclusion criteria : cardiogenic shock, unsuccessful
reperfusion to achieve antegrade flow despite aspiration
thrombectomy, acute stent thrombosis, inability to
advance an intravascular imaging catheter to the culprit
lesion, poor image quality, massive thrombus, coronary
embolism, and STEMI caused by spontaneous coronary
dissection.
All patients underwent primary PCI within 24 h after the
onset of symptoms

METHODS

ACQUISITION OF OCT IMAGE

Aspirin 200 mg, clopidogrel 300 mg, and heparin
100 IU/kg were administrated before the procedure. None
of the patients were pretreated with a thrombolytic
agent and a glycoprotein IIb/IIIa inhibitor
Manual aspiration thrombectomy (Rebirth or
Eliminate3, 7F or 6F ) restore antegrade coronary flow.
The OCT imaging catheter was then advanced distal to
the lesion
Manual aspiration thrombectomy was repeated when
image
quality was suboptimal due to large amount of residual
thrombus. Pre-dilation with balloon angioplasty was
not allowed before OCT imaging.

METHODS
OCT ANALYSIS

Plaques were categorized into plaque rupture, plaque

erosion, calcified nodule.
lipid plaque plaque with lipid arc of > 90o
Thin-cap fibroatheroma lipid plaque with the thinnest
fibrous cap thickness of <65 m.
Thrombus an irregular mass floated from the vessel
wall or attached to surface of the vessel wall with a
dimension of 250 m.
For the thrombus measurement, OCT images were
analyzed
Thrombus was categorized : erythrocyte-rich (red)
by 2 independent investigators blinded to clinical
thrombus, or platelet-rich (white) thrombus.
and angiographic data.
thrombus and lumen volume was calculated. Thrombus
burden thrombus volume divided by lumen
volume multiplied by 100 final angiogram

METHODS

ANGIOGRAPHIC ANALYSIS
evaluated baseline, post-thrombectomy, and final
antegrade coronary flow according to the TIMI criteria
No reflow TIMI flow grade 2 or TIMI flow grade 3 with
myocardial blush grade 1
Reference diameter, minimal lumen diameter,
percentage of diameter stenosis, and lesion length
were also measured.

1
0

Representative optical coherence tomography (OCT) images of a patient in the highest tertile
(large residual thrombus burden: 12.7% in the entire analyzable segment and 19.0% in the
30-mm segment). (A) A cross-sectional OCT image after thrombectomy. (B) The actual
measurements of thrombus and lumen area. Area Multiple Points software was used for
tracing of thrombus and lumen area. (C) Schematic drawing of thrombus and lumen area. (D)
Longitudinal view of postaspiration thrombectomy. White bar represents an analyzable
segment. Double arrow represents an actual measurement length of 30-mm.

RESULTS

Two patients without stent implantation were

excluded

1
1

1
2
The mean thrombus volume and burden after aspiration
thrombectomy
4.95 mm3 (95% CI: 3.11 to 6.76) and 1.62% (95% CI:
1.11 to 2.13),
The 109 patients were divided into tertiles according to the
thrombus burden within a 30-mm segment including the culprit
lesion (first tertile [T1]: <0.56%; second tertile [T2]: 0.56% to
2.38%; third tertile [T3]: >2.38%).

Thrombus Burden

1
3

1
4

There were no differences, including time

delay to reperfusion among the 3 groups.

Angiographic Characteristics

1
5

Angiographic Characteristics

The location of the culprit lesion and the angiographic

parameters were similar among the 3 groups except
that initial TIMI flow grade 1 was significantly more
frequent in T3

1
6

OCT Findings

1
7

Thrombus volume was significantly greater in T3 compared

with T1 (6.57 vs. 0.27 mm3)

Outcome After PCI

1
8

1
9

2
0

DISCUSSIO
N

2
1

The main findings of this study:

1) Residual thrombus was present after aspiration
thrombectomy irrespective of underlying mechanism
of plaque disruption or plaque morphology;
2) Greater residual thrombus burden after
thrombectomy more severe microvascular
dysfunction and greater myocardial damage after
stenting.

Aggressive removal of the thrombus at the culprit

lesion
improving outcome of primary PCI in patients with
STEMI.

2
2

DISCUSSIO
N
Successful restoration of
epicardial
blood flow

Embolization of thrombus and/or

plaque debris downstream in the
infarct-related artery

Abnormal myocardial perfusion (no reflow

Phenomenon)
increased infarct size and
mortality
Retrieving thrombi from the culprit lesion
was thought to prevent distal embolization
and to reduce no reflow phenomenon

2
3

DISCUSSIO
N

Routine aspiration thrombectomy at the time of primary PCI

resulted in improved myocardial perfusion grade reduced
infarct size and reduced mortality
(Svilaas T et al;
Sardella G et al)

Recent clinical trial failed to show an additional benefit

of routine thrombus aspiration before stenting compared with
PCI alone in STEMI
TOTAL (ThrOmbecTomy versus PCI Alone), Sirker
A et al

DISCUSSIO
N

Lack of clinical
benefit :

2
4

The presence of a large amount of residual thrombus

burden
even after aspiration thrombectomy
Small amount of thrombus burden at the culprit
lesion before
intervention
Less influence of thrombus burden on infarct size
Most aspiration thrombectomy devices are relatively
bulky; dislodge thrombus and/or plaque debris, with
subsequent embolization into the microcirculation.

DISCUSSIO
N

2
5

OCT substudy from TOTAL

No significant difference in pre-stent thrombus burden
at the culprit lesion between the 2 groups 2.36% after
aspiration in
the thrombectomy group and 2.88% after wire insertion or
balloon angioplasty in the PCI alone group (p = 0.373)
Enrollment in this study : operators discretion. Patients
with large thrombus burden might have been excluded
The potential benefit of thrombectomy might have been
mitigated.

DISCUSSIO
N
NO REFLOW

2
6

PHENOMENON
DELAYED REPERFUSION
BASELINE TIMI FLOW
ADVANCED AGE
PRE PCI THROMBUS
BURDEN
in This study there was no significant difference among
the 3 groups in onset to reperfusion time
After multivariate analysis adjusting for baseline TIMI
flow 1
The result showed that the highest tertile of
thrombus burden still remained significantly
associated with no reflow

DISCUSSIO
N

2
7

This Study showed that aspiration thrombectomy often

results in incomplete retrieval of the thrombus.
worse outcomes in patients with large residual thrombus
burden

Lack of clinical benefit of aspiration thrombectomy in the

TOTAL trial may be related to an inadequate retrieval of
thrombus using the current aspiration thrombectomy
device.

DISCUSSIO
N

2
8

Aspiration thrombectomy can no longer be

recommended as a
routine strategy in patients with STEMI
However, This study strongly more thorough removal
of thrombus is beneficial to patients with large
thrombus burden, which can be achieved by more
effective aspiration thrombectomy devices with
effective antithrombotic therapy.

DISCUSSIO
N

2
9

STUDY
LIMITATIONS
1. Single centre study
2. Small number of Subject
3. accurate tracing of the lumen border is sometimes
challenging, especially when the thrombus burden
is large.
4. Patients were not pretreated with a glycoprotein
IIb/IIIa inhibitor.
5. OCT was not performed before aspiration
thrombectomy, initial thrombus burden could not
be assessed.

CONCLUSION

3
0

Residual thrombus persists after aspiration

thrombectomy
irrespective of underlying mechanism of plaque disruption or
plaque morphology in patients with STEMI.
STEMI patients with larger residual thrombus burden
after thrombectomy had more severe microvascular
dysfunction, and greater myocardial damage compared with
those with
smaller residual thrombus burden

3
1

THANK
YOU

Critical appraisal of
Prognostic studies

A. VALIDITY : Are the results of the study

valid?

1.Was the defined representative

sample of patients assembled at a
common (usually early) point in the
course of their disease)?

2. Was patient follow-up sufficiently

long and complete?

3. Were outcome criteria either

objective or applied in a blind
fashion?
4. If subgroups with different
prognoses are identified, did
adjustment for important prognostic
factors take place?

YES
NO
YES

YES

32

B. What are the results ?

1. How likely are the outcomes
over time?

33

: C. APPLICABILITY : Can I apply this valid, important

evidence about prognosis to my patient?
Is my patient so different to those in the
study that the results cannot apply?

No

Will this evidence make a clinically

important impact on my conclusions about
what to offer to tell my patients?

YES

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dimension

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function

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