Selective Coronary Thrombectomy: CRM, June 2025 Study Finds No Increased Stroke Risk in High-Thrombus STEMI
A recent large-scale retrospective study found that selective coronary thrombectomy in patients with high thrombotic burden, especially ST-Elevation Myocardial Infarction (STEMI), is safe, with no significant increase in the risk of stroke or procedural death. While the technique was associated with higher rates of no-reflow, this likely reflects the higher clinical complexity of patients selected for the procedure rather than the technique itself.
These findings are published in June 2025 in Cardiovascular Revascularization Medicine.
The Evolving Debate Over Thrombus Aspiration
The role of manual thrombus aspiration during percutaneous coronary intervention (PCI) for patients presenting with acute coronary syndrome (ACS) has shifted dramatically over the last decade. Historically favored for reducing clot burden, the technique was downgraded by European Society of Cardiology (ESC) guidelines after major clinical trials raised concerns regarding an increased risk of stroke. Despite these recommendations against routine use, many interventionalists continue to use thrombectomy selectively in patients with high thrombotic loads, believing it optimizes blood flow and prevents distal embolization.
Study Overview
The retrospective cohort study, conducted at a single tertiary center in Portugal, analyzed 2,658 consecutive patients with ACS who underwent PCI between 2016 and 2024. The research compared patients who received adjunctive coronary thrombectomy (1,009 patients) against a control group who underwent conventional PCI (1,651 patients). The primary focus was the incidence of cerebrovascular events, specifically stroke and Transient Ischemic Attack (TIA), during hospitalization. The study included both STEMI and Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) cases to provide a robust real-world comparison.
Key Findings from the Study Include:
Among the thrombectomy cohort, 93% of patients presented with STEMI, compared to 51% in the control group, reflecting a highly selective application in emergency scenarios.
The primary endpoint of cerebrovascular events was low and comparable between groups, occurring in 0.8% of the thrombectomy group and 0.5% of the control group.
There was no statistically significant difference in stroke rates (0.6% vs 0.4%) or procedural mortality (1% vs 0.5%).
The incidence of no-reflow was significantly higher in the thrombectomy group (1.4% vs 0.2%), which researchers attributed to the higher thrombotic burden and more severe clinical presentations, such as higher Killip-Kimball class and lower Left Ventricular Ejection Fraction (LVEF), in those patients.
Clinical Relevance and Targeted Use
For practicing cardiologists, the study reaffirms that coronary thrombectomy remains a safe and valuable tool when applied with clinical judgment rather than as a routine protocol. The low incidence of stroke—comparable to conventional PCI—suggests that historical safety concerns may not apply when the procedure is performed by experienced operators using meticulous technique and appropriate catheter sizes. While the higher no-reflow rate in these patients serves as a marker for high-risk clinical scenarios, it should not necessarily discourage the use of aspiration in massive thrombus cases. Ultimately, individualized decision-making remains paramount in contemporary cardiac care.
Reference
de Almeida AR, Louro R, Neves D, et al. Adjunctive coronary thrombectomy during PCI: A single-center retrospective real-world experience. Cardiovascular Revascularization Medicine. 2026;83:17-22
