Use of Thrombus Aspiration for Patients With Acute Coronary Syndrome: Insights From the Nationwide J-PCI Registry

Abstract

Background There is significant regional or institutional variation in the use of thrombus aspiration (TA) in patients undergoing percutaneous coronary intervention (PCI). We investigated the temporal trend in TA use and its association with clinical outcomes in acute coronary syndrome using the nationwide J-PCI (Japanese PCI) registry. Methods and Results Between 2016 and 2018, patients with acute coronary syndrome undergoing PCI (n=282 606; median age, 71.0 years; interquartile range, 62.0-79.0 years; women, 24.7%) at 1124 hospitals were stratified on the basis of whether TA was performed (TA and non-TA). The patients were subdivided according to clinical presentation (ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina). Successful PCI, defined as the achievement of TIMI (Thrombolysis in Myocardial Infarction) 3 flow, and in-hospital mortality were assessed. During the study period, 83 422 patients (29.5%) underwent TA (52.9%, 23.5%, and 5.2% for ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, respectively), and the TA implementation rate remained relatively stable throughout. Patients treated with TA had higher rate of successful PCI than non-TA (98.7% versus 97.8%; P<0.001). TA was not associated with in-hospital death among patients with ST-segment-elevation myocardial infarction (adjusted odds ratio [aOR], 1.02 [95% CI, 0.94-1.12]). However, TA use was associated with higher rates of in-hospital death in patients with non-ST-segment-elevation myocardial infarction ( aOR, 1.51 [95% CI, 1.23-1.86]) or unstable angina ( aOR, 1.95 [95% CI, 1.37-2.79]). Conclusions In our retrospective analysis of the nationwide PCI registry, TA use was associated with a higher achievement of successful PCI without impairing in-hospital mortality among patients with ST-segment-elevation myocardial infarction. Nevertheless, its use should be cautioned in less-established indications (eg, non-ST-segment-elevation myocardial infarction and unstable angina).

Keywords: acute coronary syndrome; myocardial infarction; percutaneous coronary intervention; thrombus aspiration.

Figure 1. Study flowchart.

ACS indicates acute coronary syndrome; MI, myocardial infarction; NSTEMI, non–ST‐segment–elevation MI; PCI, percutaneous coronary intervention; STEMI, ST‐segment–elevation MI; TA, thrombus aspiration; and UA, unstable angina.

Figure 2. Temporal trends in the use of thrombus aspiration.

NSTEMI indicates non–ST‐segment–elevation myocardial infarction; q, quartile; STEMI, ST‐segment–elevation myocardial infarction; and UA, unstable angina.

Figure 3. Variability of thrombus aspiration use among institutes.

Median percentage of thrombus aspiration use was 27.5% (interquartile range, 16.2%–38.3%).

Figure 4. Adjusted impacts of thrombus aspiration use on in‐hospital mortality and procedure‐related complications by clinical presentations.

Overall complications were defined as a composite of in‐hospital deaths within 30 days of percutaneous coronary intervention (PCI), periprocedural myocardial infarction, cardiac tamponade, cardiogenic shock during and after PCI, emergency operations, bleeding, and other complications. NSTEMI indicates non–ST‐segment–elevation myocardial infarction; and STEMI, ST‐segment–elevation myocardial infarction.

Figure 5. The association between the use of thrombus aspiration (TA) and in‐hospital outcomes, according to the institutional volume of TA cases performed during the study period (between 2016 and 2018).

Overall complications were defined as a composite of in‐hospital death within 30 days of PCI, periprocedural myocardial infarction, cardiac tamponade, cardiogenic shock during and after PCI, emergency operations, bleeding, and other complications. The precise numbers of TAs performed for each quartile were as follows: first quartile, 0 to 16; second quartile, 17 to 27; third quartile, 28 to 38; and fourth quartile, 39 to 100.