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Randomized Controlled Trial
. 2015 Aug 1;36(29):1892-900.
doi: 10.1093/eurheartj/ehv176. Epub 2015 May 20.

Culprit lesion thrombus burden after manual thrombectomy or percutaneous coronary intervention-alone in ST-segment elevation myocardial infarction: the optical coherence tomography sub-study of the TOTAL (ThrOmbecTomy versus PCI ALone) trial

Ravinay Bhindi  1 , Olli A Kajander  2 , Sanjit S Jolly  3 , Saleem Kassam  4 , Shahar Lavi  5 , Kari Niemelä  2 , Anthony Fung  6 , Asim N Cheema  7 , Brandi Meeks  3 , Dimitrios Alexopoulos  8 , Viktor Kočka  9 , Warren J Cantor  10 , Timo P Kaivosoja  2 , Olga Shestakovska  3 , Peggy Gao  3 , Goran Stankovic  11 , Vladimír Džavík  12 , Tej Sheth  13
Affiliations
Randomized Controlled Trial

Culprit lesion thrombus burden after manual thrombectomy or percutaneous coronary intervention-alone in ST-segment elevation myocardial infarction: the optical coherence tomography sub-study of the TOTAL (ThrOmbecTomy versus PCI ALone) trial

Ravinay Bhindi et al. Eur Heart J. .

Abstract

Aims: Manual thrombectomy has been proposed as a strategy to reduce thrombus burden during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, the effectiveness of manual thrombectomy in reducing thrombus burden is uncertain. In this substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial, we compared the thrombus burden at the culprit lesion using optical coherence tomography (OCT) in patients treated with thrombectomy vs. PCI-alone.

Methods and results: The TOTAL trial (N = 10 732) was an international, multicentre, randomized trial of thrombectomy (using the Export catheter, Medtronic Cardiovascular, Santa Rosa, CA, USA) in STEMI patients treated with primary PCI. The OCT substudy prospectively enrolled 214 patients from 13 sites in 5 countries. Optical coherence tomography was performed immediately after thrombectomy or PCI-alone and then repeated after stent deployment. Thrombus quantification was performed by an independent core laboratory blinded to treatment assignment. The primary outcome of pre-stent thrombus burden as a percentage of segment analysed was 2.36% (95% CI: 1.73-3.22) in the thrombectomy group and 2.88% (95% CI: 2.12-3.90) in the PCI-alone group (P = 0.373). Absolute pre-stent thrombus volume was not different (2.99 vs. 3.74 mm(3), P = 0.329). Other secondary outcomes of pre-stent quadrants of thrombus, post-stent atherothrombotic burden, and post-stent atherothrombotic volume were not different between groups.

Conclusion: Manual thrombectomy did not reduce pre-stent thrombus burden at the culprit lesion compared with PCI-alone. Both strategies were associated with low thrombus burden at the lesion site after the initial intervention to restore flow.

Keywords: Myocardial infarction; Optical coherence tomography; STEMI; Thrombectomy; Thrombus.

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Conflict of interest statement

T.S. reports grants and personal fees from St Jude Medical, during the conduct of the study; W.J.C. reports personal fees from AstraZeneca, Roche Canada, and Daiichi Sankyo, outside the submitted work; A.F. reports personal fees from Proctor for St Jude Medical, outside the submitted work; S.S.J. reports grants from Medtronic and St Jude, during the conduct of the study; V.K. reports grants, personal fees, and non-financial support from Medtronic, personal fees and non-financial support from Abbott Vascular, non-financial support from B. Braun, outside the submitted work.

Figures

Figure 1
Figure 1
Measurement of thrombus burden by OCT in two STEMI patients in TOTALOCT study. Representative cross-sectional OCT images of a patient with high (22.1%) pre-stent TB (A1–6) and another patient with low (3.4%) pre-stent TB (B1–6). Anatomically matched cross-sections of the culprit artery show the original pre-stent lumen area (Area A) and flow area (Area B) tracings in A1–3 and B1–3 and post-stent modified stent area (Area A) and flow area (Area B) tracings in A4–6 and B4–6. Intraluminal thrombus can be observed in cross sections (denoted by asterisks in A2 and A5) and in the longitudinal view (arrows in A2 and A5). An example of post-stent measurements in case of malapposition is shown in B4. Post-stent atherothrombotic burden was 10.2 and 2.7%, respectively, for patients A and B. OCT, optical coherence tomography, STEMI, ST-elevation myocardial infarction.
Figure 2
Figure 2
Patient flow diagram. Asterisk indicates TIMI 2/3 flow achieved, but vessel reoccluded by imaging catheter.
Figure 3
Figure 3
Scatter plot of pre-stent thrombus burden by treatment group.
Figure 4
Figure 4
Scatter plot of pre-stent thrombus volume by treatment group.
Figure 5
Figure 5
Correlation between pre-stent thrombus burden and post-stent atherothrombotic burden. burden
See this image and copyright information in PMC

Comment in

References

    1. Steg PG, James SK, Atar D, Badano LP, Blomstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van’t Hof A, Widimsky P, Zahger D. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569–2619. - PubMed
    1. Lagerqvist B, Frobert O, Olivecrona GK, Gudnason T, Maeng M, Alstrom P, Andersson J, Calais F, Carlsson J, Collste O, Gotberg M, Hardhammar P, Ioanes D, Kallryd A, Linder R, Lundin A, Odenstedt J, Omerovic E, Puskar V, Todt T, Zelleroth E, Ostlund O, James SK. Outcomes 1 year after thrombus aspiration for myocardial infarction. N Engl J Med. 2014;371:1111–1120. - PubMed
    1. Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ, Kedev S, Thabane L, Stankovic G, Moreno R, Gershlick A, Chowdhary S, Lavi S, Niemela K, Steg PG, Bernat I, Xu Y, Cantor WJ, Overgaard CB, Naber CK, Cheema AN, Welsh RC, Bertrand OF, Avezum A, Bhindi R, Pancholy S, Rao SV, Natarajan MK, Ten Berg JM, Shestakovska O, Gao P, Widimsky P, Dzavik V, Investigators T. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372:1389–1398. - PMC - PubMed
    1. Prati F, Capodanno D, Pawlowski T, Ramazzotti V, Albertucci M, La Manna A, Di Salvo M, Gil RJ, Tamburino C. Local delivery versus intracoronary infusion of abciximab in patients with acute coronary syndromes. JACC Cardiovasc Interv. 2010;3:928–934. - PubMed
    1. Onuma Y, Thuesen L, van Geuns RJ, van der Ent M, Desch S, Fajadet J, Christiansen E, Smits P, Holm NR, Regar E, van Mieghem N, Borovicanin V, Paunovic D, Senshu K, van Es GA, Muramatsu T, Lee IS, Schuler G, Zijlstra F, Garcia-Garcia HM, Serruys PW. Randomized study to assess the effect of thrombus aspiration on flow area in patients with ST-elevation myocardial infarction: an optical frequency domain imaging study—TROFI trial. Eur Heart J. 2013;34:1050–1060. - PubMed

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