Thrombectomy in acute myocardial infarction: Current evidence, challenges, and emerging technologies

Abstract

Thrombus burden significantly increases risk of no-reflow and microvascular obstruction and subsequently impacts outcomes in acute myocardial infarction (AMI). While initial studies suggested benefits of thrombus aspiration (TA), recent large trials have questioned its routine use. This review examines the role of thrombectomy in the management of AMI, focusing on its potential to improve myocardial perfusion and mitigate no-reflow risk. Attention should be focused on recognising high thrombus burden and its effect on major adverse cardiovascular events and impaired myocardial reperfusion. Similarly, standardising TA techniques and ensuring appropriate patients’ selection may also improve enhance our understanding of the role of thrombectomy in AMI. Emerging technologies such as stent retrievals and mechanical thrombectomy may overcome the limitations of manual thrombectomy devices.

Key Words: Myocardial infarction; Primary percutaneous coronary intervention; Thsrombectomy; Thrombus aspiration; Myocardial reperfusion; Distal embolization; Microvascular obstruction; ST elevation myocardial infarction; No-reflow; Slow-reflow phenomena

Core Tip: Thrombus aspiration during acute myocardial infarction (AMI) is a debatable subject. Previous studies highlighted its inefficacy when it is performed routinely. Several limitations were recognised, and studies neutral results may be related to the used device rather determining the efficacy of thrombectomy as concept. Emerging technology and optimal patient selection may allow addressing the role of thrombectomy in AMI.

INTRODUCTION

Primary percutaneous coronary intervention (PPCI) remains the default strategy in restoring blood flow in patients presenting with acute myocardial infarction (AMI) with ST-segment elevation (STEMI)[1]. Failure to achieve optimal reperfusion following PPCI can result in large myocardial damage, leading to necrosis, arrhythmia, and cardiac dysfunction[2].

No-reflow phenomenon (NRP) is a significant complication observed in patients undergoing PPCI[3,4]. Despite successful restoration of epicardial coronary blood flow, up to 50% of patients do not achieve optimal myocardial reperfusion[5,6]. NRP is characterized by reduced coronary antegrade flow which is quantified using thrombolysis in myocardial infarction (TIMI) grade, without any apparent stenosis or dissection of the infarct-related artery (IRA)[7]. This phenomenon is relatively complex, and several factors contribute to its development including thrombus burden at the site of the ruptured atherosclerotic plaque[7,8]. Additionally, distal embolization of atherothrombotic debris from the culprit lesion is a recognised complication during PPCI[9]. This can occur spontaneously or during various stages of the PCI procedure, including guide-wire passage, lesion preparation, and stent implantation[10,11]. While angiographically visible distal embolization is documented in 11%-17% of PPCI procedures, the true incidence of smaller emboli is likely higher[12]. The embolized material typically comprises a mixture of atheromatous debris, platelet aggregates, erythrocytes, fibrin, cholesterol crystals, and inflammatory cells[12,13]. Collectively, these phenomena have been associated with suboptimal microvascular function, which in turn has been linked to significant in-hospital adverse events, persistent STEMI, reduced left ventricular (LV) function, and large infarct size[14,15].

Various strategies have been studied to reduce the risk of distal embolization and NRF to improve myocardial reperfusion in STEMI patients. These include direct stenting, deferred stenting, distal protection devices, and thrombectomy[16-18]. Among these approaches, thrombectomy has received significant attention with mixed results from previous studies. This review article aims to explore the role of thrombectomy in STEMI management, focusing on its potential to improve myocardial perfusion and mitigate the risk of no-reflow.

NO REFLOW PHENOMENON

The NRF, including distal embolization, is a dreaded complication in patients presenting with STEMI undergoing PPCI. It results in inadequate myocardial perfusion despite successful reopening of the IRA[19,20]. This phenomenon is closely linked to microvascular obstruction (MVO), and potentially intra-myocardial haemorrhage[21].

Several factors increase the risk of distal embolization, including larger plaque volumes (especially those with a large necrotic core), higher thrombus burden at the culprit site, erythrocyte-rich thrombi, elevated admission glucose, larger culprit vessel diameter, pre-dilation, and right coronary artery as the culprit vessel[22]. Distal embolization can lead to patchy microinfarcts, increased biomarkers of myocardial necrosis, and impaired LV function disproportionate to the actual amount of embolized material[23].

The mechanisms by which distal embolization promotes MVO and no-reflow are multifaceted, including mechanical obstruction, release of vasoconstrictor substances, generation of a prothrombotic milieu favoring platelet aggregation and in situ thrombosis, and induction of a local inflammatory response[24,25]. Notably, embolized material tends to flow to well-perfused viable myocardium rather than the central infarct zone, potentially extending infarct size[7].

Similarly, numerous factors have been identified as predictors of no-reflow in STEMI patients. The atherogenic index of plasma which is a novel biomarker associated with atherosclerosis and cardiovascular disease risk. It is calculated as the logarithm of the ratio of triglycerides to high-density lipoprotein cholesterol in plasma. It has been found to be an independent predictor, with higher values observed in the no-reflow group compared to the reflow group[20]. Other factors associated with no-reflow include age, pain-to-PCI time, neutrophil count, admission plasma glucose level, pre-PCI thrombus score (Table 1), collateral circulation, and Killip class[26]. Inflammatory markers such as fibrinogen-to-albumin ratio, platelet-to-lymphocyte ratio, and neutrophil-to-lymphocyte ratio have also shown promise in predicting no-reflow[27,28].

Table 1 Thrombus score classification using coronary angiography.

Thrombus grade	Definition
Grade 0	No thrombus
Grade 1	Possible thrombus
Grade 2	Small (greatest dimension ≤ 1/2 VD
Grade 3	Moderate (> 1/2 but < 2 VD)
Grade 4	Large (≥ 2 VD)
Grade 5	Unable to assess TB due to vessel occlusion

2 VD: Two times vessel diameter; TB: Thrombus burden.

The age-thrombus burden-index of microcirculatory resistance (ATI) score, which incorporates age, thrombus burden, and index of microcirculatory resistance (IMR) pre-stenting (defined as IMR > 40), serves as a valuable diagnostic tool for predicting suboptimal myocardial reperfusion and microvascular impairment[29,30]. Patients who had a thrombus score less than 5 were less likely to develop impairment in microcirculation. This score has been validated against cardiac magnetic resonance imaging (MRI) and demonstrates a strong correlation with MVO, and final infarct size[29]. It is well established MVO, detected on MRI, is a recognised high risk feature and is strongly linked to increased mortality rates and heart failure hospitalizations within the first year following STEMI[31]. Remarkably, the thrombus burden carried the greatest weight in the development of NRP according to the ATI score and its relationship with clinical outcomes will be discussed next.

THE ASSOCIATION BETWEEN THROMBUS BURDEN AND CLINICAL OUTCOMES

High thrombus burden (HTB) in patients presenting with AMI is associated with worse clinical outcomes, including higher mortality rate[29,32,33]. The presence of a large thrombus poses significant challenges during PPCI and can lead to procedural complications such as NRP, stent thrombosis, and MVO[34]. Previous study highlighted that patients with large thrombus burden (grade 4-5), had significantly higher rates of 30-day MACE compared to those with small thrombus burden (17.1% vs 9.7%, P < 0.001)[35]. This finding underscores the clinical importance of thrombus burden assessment in STEMI patients. Furthermore, HTB was found to be an independent predictor of distal embolization (odds ratio 1.74, 95%CI: 1.17-2.58, P = 0.006), highlighting its role in compromising downstream microvascular perfusion.

The influence of HTB on myocardial reperfusion has been the subject of extensive investigation. Impaired myocardial reperfusion, commonly evaluated invasively using myocardial blush grade (MBG) and non-invasively via ST-segment resolution, is correlated with larger infarct sizes and adverse long-term outcomes. A comprehensive meta-analysis of individual patient data from over 18000 participants in major thrombus aspiration (TA) studies (TAPAS, TASTE, and TOTAL) demonstrated that patients with a substantial thrombus burden (TIMI thrombus grade 3 or more) exhibited a significantly higher rate of cardiovascular mortality at 30 days compared to those with a smaller thrombus burden (< 3)[36]. However, the difference in all-cause mortality was not statistically significant. This trend persisted at the one-year follow-up, with cardiovascular mortality remaining significantly elevated in patients with large thrombus scores, while all-cause mortality showed no significant difference but numerically higher in patients with HTB. Furthermore, when patients were categorized using a thrombus score threshold of 4, those with scores ≥ 4 exhibited higher all-cause mortality compared to patients with scores < 4 at 30 days. However, this difference was not sustained at the one-year follow-up. Thrombus score remains a modifiable feature using thrombectomy tools, but whether reducing thrombus burden effectively is translated into a reduction in the risk of MVO and subsequently major adverse events is yet to be determined.

Thrombectomy

Given the impact of HTB on clinical outcomes and myocardial reperfusion, the value of TA in STEMI remains a subject of debate in interventional cardiology. The main goal of TA is to eliminate the clot where an acute plaque rupture has occurred, potentially improving flow in the infarcted artery and achieving effective tissue reperfusion[32-34].

Initial studies explored the impact of TA on myocardial reperfusion using proxy measures of clinical outcomes. The REMEDIA trial, a prospective single-center study, randomly assigned 100 consecutive patients to either manual TA with a 6-French Diver CE catheter or standard treatment prior to coronary angiography. The study's primary endpoints were post-procedural angiographic and electrocardiographic parameters. The results demonstrated enhanced myocardial reperfusion with TA compared to PCI alone with almost 2.5 folds increase in the rate of better perfusion using TA[37].

These findings were corroborated by the EXPIRA study, which included 175 STEMI patients and showed a higher rate of MBG ≥ 2 and a higher rate of ST-segment resolution > 70% in the TA group compared to the standard PCI group. A sub-study of EXPIRA, utilizing contrast-enhanced cardiac MRI in 75 patients, revealed a significant decrease in MVO and infarct size at 3 months with TA use[38].

The TAPAS trial was a large prospective randomized controlled study involving 1071 patients, employed a 6-French Export Aspiration Catheter. This study not only showed improved microvascular reperfusion with TA but also demonstrated a reduction in cardiovascular mortality at 1 year[39].

The ATTEMPT study, which include data from 11 randomized trials with 2686 STEMI patients undergoing PCI, found that thrombectomy significantly reduced all-cause mortality, MACE, and death plus MI rates. Manual thrombectomy particularly improved survival, with enhanced benefits when combined with IIb/IIIa-inhibitors[40]. In a later meta-analysis, De Luca et al[40] found that using adjunctive manual TA during primary PCI for AMI patients significantly reduced 30-day mortality. An updated meta-analysis of 20 trials, including TAPAS, also indicated mortality benefits at 6-12 months.

While these studies suggested potential benefits of TA in STEMI patients, more recent large-scale clinical trials have challenged these findings. The TOTAL trial, a randomized controlled study involving 10732 patients, found no significant reduction in cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days with routine manual thrombectomy compared to PCI alone[41-44]. Moreover, the trial observed an increased risk of stroke (almost two-fold) within 30 days in the thrombectomy group[44,45]. Notably, the difference in stroke incidence between the two groups continues to widen beyond the 1-year follow-up period, which raises questions about the causal link to TA usage[46].

The efficacy of TA in patients presenting with large anterior MI was evaluated in the INFUSE-AMI study. This trial involved 452 individuals who presented with occlusions in the proximal or mid-left anterior descending (LAD) artery. The primary objective was to determine if TA could provide any advantages of reducing infarct size. However, MRI assessments conducted 30 days post-intervention revealed comparable infarct size in patients who underwent or did not undergo TA[47,48]. Additionally, the TASTE (TA in ST-elevation myocardial infarction in Scandinavia) trial, a large-scale randomized controlled study encompassing 7244 patients with (STEMI), demonstrated that routine TA did not confer a significant reduction in 30-day mortality compared to PCI alone (2.8% vs 3.0%, respectively)[49-51]. Furthermore, the trial revealed no statistically significant differences between the two groups in terms of secondary outcomes, including recurrent myocardial infarction, stent thrombosis, or stroke. Notably, these findings remained consistent across all major subgroups, including patients with HTB. Subsequent analysis at one-year follow-up corroborated the initial results.

Overall, these trials provide stronger evidence against the routine use of manual thrombectomy in STEMI patients, contradicting the earlier positive findings from smaller studies (Table 2). As a result, current guidelines have been updated to reflect this new evidence, with manual thrombectomy no longer recommended as a routine strategy in primary PCI for STEMI[1].

Table 2 Landmark studies on thrombectomy in acute myocardial infarction.

Ref.	Sample size	Design and randomisation	TA catheter type	Primary endpoint	Finding
Byrne et al[1] (REMEDIA)	100 STEMI	Standard PCI (n = 49) vs Manual TA (n = 50)	Diver CE catheter	Post-procedure myocardial blush grade ≥ 2, and ST segment resolution ≥ 70%	TA improves MBG (≥ 2) and STR (68.0% and 44.9% vs 58.0% and 36.7%, respectively) with OR 2.6 (95%CI: 1.2-5.9; P = 0.020) and OR 2.4 (95%CI: 1.1-5.3; P = 0.034), respectively. Direct stenting was more frequently used in TA than standard PCI groups (66% vs 24%). TA is feasible and improves the angiographic and ECG criteria of myocardial reperfusion compared to PCI alone
Szummer et al[2] (EXPIRA)	175 STEMI +	Standard PCI (n = 87) vs Manual TA + PCI (n = 88)	Export Medtronic catheter	Post-procedure myocardial blush grade ≥ 2, and ST segment resolution ≥ 70% at 90 min post-procedure	TA improved MBG (≥ 2) and STR (88% vs 60%; P = 0.001; and 64% vs 39%; P = 0.001). The extent of microvascular obstruction defined by contrast-enhanced cardiac MRI was significantly lower in the TA group; TA significantly reduced infarct size at 3 months, and lower cardiac death was observed at 9 months
Rezkalla et al[3], Iwakura et al[4] (TAPAS)	1071 STEMI	Standard PCI (n = 536), manual TA + PCI (n = 535)	Export Medtronic catheter	MBG of 0 or 1, indicating poor myocardial perfusion	MBG of 0 or 1 was significantly lower in the TA group (17.1%) compared to the conventional PCI group (26.3) (P < 0.001). Complete ST-segment resolution was more frequent in the TA group (56.6% vs 44.2%, P < 0.001), 30-day mortality was significantly lower in the TA group (3.6% vs 6.7%, P = 0.02), one-year mortality was also lower in TA group (3.6% vs 6.7%, P = 0.01)
van Lavieren et al[5], van 't Hof et al[6], Ndrepepa et al[7] (INFUSE-AMI)	452 STEMI ++	Prospective,open-label, randomized, controlled trials, using a 2 × 2 factorial design, were andomized to: (1) Intracoronary abciximab infusion; (2) No intracoronary abciximab; (3) TA; and (4) No TA	Export Medtronic catheter	Reduction in infarct size (measured by cardiac MRI at 30 days)	The intra-coronary Abciximab arm at 30 days showed a reduced infarct size (measured by cardiac MRI) compared to no Abciximab (median 15.1%; IQR: 6.8%-22.7%; n = 181, vs 17.9%; IQR: 10.3%-25.4%; n = 172; P = 0.03). TA vs no TA showed no difference in infarct size at 30 days (median 17.0%; IQR: 9.0%-22.8%; n = 174, vs 17.3%; IQR: 7.1%-25.5%; n = 179; P = 0.51) as well as no mortality difference at 1 year
Vrints et al[8], Kirtane et al[9] (TASTE)	7244 STEMI	Multicentre, randomized, controlled, open-label trial, Thrombus aspiration + PCI vs PCI alone	Multiple catheters	All-cause mortality at 30 days. Secondary endpoints are recurrent myocardial infarction, stent thrombosis, heart failure, and cardiogenic shock	Death from any cause occurred in 2.8% (TA group) vs 3.0% (PCI group) (HR = 0.94; 95%CI: 0.72-1.22; P = 0.63). Routine TA before PCI did not affect 30-day mortality compared to PCI alone[44]. There was no reduction in death from any cause or composite of death, myocardial infarction, or stent thrombosis at 1 year
Matsuo et al[10], Yaméogo et al[11] (TOTAL)	10732 STEMI	Multicentre, randomized, controlled, open-label trial comparing routine aspiration thrombectomy + PCI vs PCI alone	Export Medtronic catheter	Cardiovascular death, myocardial infarction, cardiogenic shock, or class IV heart failure at 180 days	Primary outcome occurred in 6.9% (TA group) vs 7.0% in PCI-only group (HR = 0.99; 95%CI: 0.85-1.15; P = 0.86) with no reduction in CV death, recurrent myocardial infarction, cardiogenic shock, or heart failure within 180 days. Primary outcome at 1 year occurred in 8% of each group (HR 1.00; 95%CI: 0.87-1.15; P = 0.99). CV death at 1 year was reported as 4% in each group (HR = 0.93; 95%CI: 0.76-1.14; P = 0.48)
Keeley et al[12] (NATURE study)	148 STEMI patients till Dec 2014	Randomized, multicentre clinical trial: Compare the safety and efficacy of the enVast™ system as an adjunctive measure to conventional intervention vs the standard of care in STEMI patients with significant thrombus burden	EnVast	The study aims to determine if the enVast™ device can improve procedural success and long-term outcomes in this patient population	The enVast™ thrombectomy catheter represents a promising advancement in treating STEMI patients with significant thrombus burdens. These ongoing studies are expected to provide more definitive evidence regarding its role in improving clinical outcomes

REMEDIA: The randomized evaluation of the effect of mechanical reduction of distal embolization by thrombus-aspiration in primary and rescue angioplasty; TA: Thrombus aspiration; PCI: Percutaneous coronary intervention; ST: St segment; ECG: Electrocardiogram; STEMI: ST elevation myocardial infarction; MBG: Myocardial blush grade; STR: ST segment reduction; MRI: Magnetic resonance image; EXPIRA: Thrombectomy with export catheter in infarct-related artery during primary percutaneous coronary intervention; TAPAS: Thrombus aspiration during percutaneous coronary intervention in acute myocardial infarction study; INFUSE-AMI: Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction; IQR: Interquartile range; TASTE: Thrombus aspiration during ST-segment elevation myocardial infarction; TOTAL: A trial of routine aspiration thrombectomy with percutaneous coronary intervention vs percutaneous coronary intervention alone; CV: Cardiovascular; HR: Heart rate; NATURE (NAtuRE): EnVast as an adjunct primary percutaneous coronary intervention in subjects presenting with coronary occlusions.

THE DISCORDANCE BETWEEN MANAGING THROMBUS BURDEN AND ITS IMPACT ON CLINICAL OUTCOMES

The discordance between early positive studies and late negative results serves as a cautionary tale in interpreting preliminary data and emphasizes the need for continuous reassessment of TA. Notably, a recent meta-analysis by Bianchini et al[46], encompassing 28 studies, highlighted improvement in left-ventricle function in response to TA[49]. This was evident in certain scenarios related to total ischemic time, involvement of the LAD artery, and the TA technique. Therefore, it is important to develop better granularity of the previously reported large clinical trials in order to design a study that can conclusively address the use of TA.

Firstly, there was an absence of standardized technical procedures to guide TA during PPCI. Some operators chose to navigate through the culprit lesion and then try to extract the thrombus by using negative pressure during the pullback procedure. This approach might diminish the effectiveness of TA and heighten the risk of distal embolization. The volume of vacuum syringes was not standardized, and frequently, only one syringe was employed during thrombectomy. Moreover, there was no recommendation on how to retrieve the thrombectomy catheter by maintaining negative pressure and deep intubation of the guiding catheter to avoid the theoretical risk of thrombus dislodgement, which could lead to peripheral embolization and stroke[50].

Secondly, recent RCTs have included a wide spectrum of patients with varying thrombus burdens. The primary goal of TA is clot removal from the culprit lesion and patients with small or no visible thrombus burden are unlikely to benefit from such technique. This would result in diluting the true effect of TA when assessed in a large randomized clinical trial. A more targeted approach, focusing on patients with significant thrombus burden, may provide better insights into the true effect of TA in patients presenting with STEMI and HTB. A patient-level meta-analysis combining data from three major thrombectomy trials (TOTAL, TASTE, and TAPAS) demonstrated a modest reduction in cardiovascular mortality associated with TA in the HTB subgroup (TIMI thrombus grade ≥ 3)[36]. This effect was not observed in patients with low thrombus burden or in the overall study population, highlighting the importance of a selective TA approach based on patient characteristics.

Finally, the efficacy of current manual thrombectomy catheters has been questioned recently[52,53]. Manual thrombectomy devices have relatively small crossing profiles ranging from 0.065 to 0.068 inches, and both angiographic and imaging data suggests that these catheters often leave behind large residual thrombus burden (rTB)[52] (Figures 1 and 2). This rTB would inevitably increase the risk of distal embolization and NRP and maybe linked to worse clinical outcomes. In fact, data from the TOTAL trial highlighted that one-third of patients had large rTB despite manual thrombectomy[52]. More importantly, this group had a significantly higher risk—over 80% increase—in MACE, including higher cardiovascular death[52,53]. Therefore, better and more effective thrombectomy tools are needed to appropriately address the concept of TA in patients presenting with STEMI.

Figure 1 Large retrieved thrombus using standard thrombectomy catheter. Multiple fragments of large dark red thrombus (orange arrows) from a patient presenting with acute myocardial infarction.

Figure 2 Large residual thrombus burden despite multiple thrombectomy attempts. Filling defect (orange arrow) within the distal right coronary artery segment, despite multiple thrombectomy runs. A: Shows the angiogram picture before wiring, mid blocked with high thrombus burden lesion; B: Showed large amount of residual thrombus at the distal right coronary artery despite multiple thrombectomy attempts.

EMERGING THROMBECTOMY TECHNOLOGIES AND FUTURE VISION FOR IMPROVEMENT

Given the aforementioned limitations of current TA tools, emerging technology may allow to overcome some of these limitations by enhancing thrombus retrieval, aiming to improve clinical outcomes.

The Indigo CAT RX Aspiration System, developed by Penumbra Inc. in Alameda, CA, United States, is an advanced mechanical thrombectomy device. This system utilizes continuous aspiration through an enlarged aspiration port and lumen, potentially offering superior capabilities compared to manual aspiration catheters. This design offers more powerful and consistent vacuum and prevent the scenario of distal collapse of the tip of manual thrombectomy catheter. It was initially employed in neurovascular interventions for ischemic stroke treatment, but its application has expanded to other areas such as coronary and pulmonary interventions. The CHEETAH Study reported the safety profile of continuous mechanical thrombectomy in 400 AMI patients with TIMI thrombus grades 4 and 5[54]. This single-arm study was conducted in 25 United States hospitals from August 2019 to December 2020. The primary endpoint was defined as per the TOTAL study and included cardiovascular death, recurrent MI, cardiogenic shock, and NYHA IV heart failure with event rate of 3.6% at 30 days. Furthermore, the study reported very high rate of final MBG grade 3 post-procedure of 99.75%, and TIMI flow III 97.5%[54]. These findings suggest promising outcomes for this innovative approach in managing high-risk thrombotic events.

Stent retrieval catheter, such as Envast (formerly known as the NeVa) or Solitaire, have also been applied in the coronary space[55]. Spirito et al[52] assessed the use of EnVast in 61 patients with AMI and HTB. The study highlighted the safety profile of the device with only one patient experiencing side-branch embolization, which was subsequently resolved using vacuum-assisted aspiration. While 23% of patients experienced reversible coronary spasm, no instances of coronary dissection or perforation were observed. The EnVast catheter's performance prior to stenting was noteworthy, with only 10% of patients exhibiting TIMI flow < 3, and approximately 25% achieving MBG < 2[55].

Alternative approaches for thrombus removal in AMI patients have been explored. The literature includes reports of successful thrombus retrieval from ectatic coronary arteries using a self-expanding nitinol stent device (Solitaire, Medtronic)[56,57]. An ongoing randomized controlled trial is evaluating the efficacy and safety of this stent retrieval technology compared to standard PCI or manual thrombectomy in patients with substantial thrombus burden. The trial's primary outcome measure is the reduction in thrombus load, assessed by OCT[58-60].

Overall, there is an urgent need to further advance the field of thrombectomy to enhance patient outcomes. Suggested areas for improvement include the evaluation of long-term outcomes to assess these new technologies and the design of comparative effectiveness studies that compare emerging technologies, such as Indigo CAT RX, EnVast, and Solitaire, with current thrombectomy catheters. We also posit that further research could optimize patient selection by identifying subgroups that may benefit most from thrombectomy, potentially based on thrombus characteristics and clinical presentation, to maximize the benefits of thrombectomy. We propose that coronary imaging, particularly OCT, might play a future role in guiding thrombectomy procedures and assessing their impact on clinical outcomes. Moreover, conducting comprehensive economic evaluations is crucial to ensure that the widespread adoption of these technologies is financially viable for healthcare systems.

CONCLUSION

The thrombus burden exerts a significant influence on outcomes in AMI. HTB increases the risk of NRF, distal embolization, and MVO, thereby compromising the success of PPCI and patient outcomes. Although initial studies indicated potential benefits of TA, recent large-scale trials have questioned its routine application, necessitating a re-evaluation of TA strategies in the management of STEMI. Emerging thrombectomy technologies, showed some promise in overcoming the limitations of traditional manual thrombectomy devices, and may allow to address the concept of TA in patients presenting with STEMI. As the field evolves, clinicians should consider incorporating newer thrombectomy technologies and integrating this technique into a comprehensive treatment strategy. Continued participation in clinical trials and vigilant monitoring for potential complications will be crucial in refining best practices and optimizing patient outcomes.