The false illusion of coronary thrombus device-management

Article

Primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) has contributed, in association with optimized antithrombotic therapy, to a dramatic decline in mortality over the last decades (1). Among the numerous mechanisms that may participate to non-optimal myocardial reperfusion during or after the ischemia-reperfusion process, distal embolization of thrombus or debris during primary PCI appears as a cause to be prevented (2,3). Several device-based strategies have been evaluated aiming at improving reperfusion success by reducing distal vessel occlusion and microvascular obstruction (4).

Filter devices for distal protection were intuitively relevant but, although visible debris could be captured, randomized studies failed to show a benefit in terms of reperfusion, final infarct size, and clinical outcome (5-7). To avoid distal embolization by mobilization of coronary thrombus during the acute phase of MI, another approach suggested to delay stenting when TIMI flow was preserved on the initial coronary angiogram. Of four randomized trials, only one (8), with the smallest population size, suggested a reduction of no-reflow and an improved myocardial salvage while the three others (9-11) reported no benefit on microvascular obstruction and clinical endpoints
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