Primary PCI for STEMI: still a role for thrombus aspiration

The ACC/AHA/SCAI guidelines have been updated so that routine thrombectomy during primary PCI for STEMI has been given a class III indication and selective or bailout thrombectomy has been given a class IIb indication due to lack of data. Based on the evidence from large randomized trials, thrombectomy should not be used routinely during PPCI for STEMI. Instead, it should be used a bailout strategy in cases of heavy thrombus that do not respond to balloon pre-dilatation.Technical tips such as advancing the guiding catheter tip in the coronary artery and maintaining negative pressure on the aspiration catheter as it is withdrawn, or allow a retrograde blood spill-over from the guiding catheter after the aspiration catheter is removed are small technical measures but important to improve the safety of this procedure.The newest study (Swedish Coronary Angiography and Angioplasty Registry (SCAAR)) is the largest prospective study of thrombus aspiration in primary percutaneous coronary intervention (PCI) which showed thrombus aspiration was not associated with a reduction in mortality, confirming the results from the large randomized clinical trials TASTE and TOTAL. Also, in this study, thrombus aspiration was not associated with increased risk of in‐hospital stroke; and it was associated with decreased risk of stent thrombosis.Thrombus aspiration does not improve outcomes when used systematically; it is still a valuable tool; and in selected patients, it might improve outcome.