Author + information
- Tilak Pasala1,
- Kathir Balakumaran1,
- Rama Dilip Gajulapalli1,
- Arun Kanmanthareddy2,
- Shari Bolen1,
- Meera Kondapaneni1 and
- Ajay J. Kirtane3
The evidence for the use of conventional percutaneous coronary intervention (cPCI), manual thrombectomy (MT) and mechanical thrombectomy (McT) during primary PCI (PPCI) for ST-segment elevation myocardial infarction (STEMI) is conflicting. Moreover, there is a dearth of direct evidence comparing MT versus McT. A network meta-analysis allows for indirect comparisons in a head-to-head fashion.
Electronic search of PubMed, EBSCO, Google Scholar and abstracts from conferences identified 41 randomized trials (Fig 1A) that compared the use of at least 2 of the 3 strategies (cPCI, MT, and McT) during PPCI. Mixed treatment analysis was performed for the earliest available (1-36 months) clinical and procedural endpoints.
When compared with cPCI, MT and McT were associated with a lower incidence of major adverse cardiovascular events (MACE), which is a composite of death, myocardial infarction (MI) and target vessel revascularization (TVR)(Fig 1B). The rate of complete ST-segment resolution (> 50-70%) at 60 minutes (STR) and post-procedural myocardial blush grade ≥ 2 (MBG) were higher with MT and McT (Fig 1B). Additionally, MT was associated with a lower incidence of MI and higher final ejection fraction (EF) compared to cPCI (Figs 1B and 1C). However, MT was no different than McT for all the endpoints. No statistical inconsistency was noted in the network. MT was highest in hierarchical ranking order (highest to lowest) by comparative efficacy for death, MI, stent thrombosis, MBG, EF (up to 3 months) and final infarct size (up to 3 months) while McT was highest for MACE, TVR and STR (Fig 1D). cPCI was lowest in the hierarchical ranking order for all endpoints.
Reducing the thrombus burden during PPCI for STEMI with either MT or McT improves clinical outcomes and procedural efficacy compared to cPCI.