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Long-term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials.

ABSTRACT: Randomized clinical trials that examined long-term clinical outcomes of routine aspiration thrombectomy prior to primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction have yielded different results. We hypothesized that the routine use of manual thrombus aspiration prior to primary PCI lacks long-term clinical benefits. Electronic databases were searched for randomized trials comparing routine aspiration thrombectomy and conventional PCI. We included only trials that reported clinical outcomes beyond 6 months. The primary outcome was all-cause mortality, and the secondary outcomes included major adverse cardiovascular events, re-infarction, cardiovascular mortality, and stent thrombosis (ST). A DerSimonian-Laird model was used to construct the summary estimates risk ratio (RR). We retrieved 18 trials with 20 641 ST-segment elevation myocardial infarction patients, of whom 10 331 patients underwent routine aspiration thrombectomy prior to primary PCI. At a mean follow-up of 12 months, there was no significant decrease in the risk of all-cause mortality (RR: 0.93, 95% confidence interval [CI]: 0.82-1.05, P = 0.22), major adverse cardiac events (RR: 0.95, 95% CI: 0.87-1.03, P = 0.18), re-infarction (RR: 0.95, 95% CI: 0.80-1.13, P = 0.59), cardiovascular mortality (RR: 0.80, 95% CI: 0.47-1.36, P = 0.40), or ST (RR: 0.80, 95% CI: 0.63-1.01, P = 0.06) with routine aspiration thrombectomy. Routine aspiration thrombectomy prior to primary PCI was not associated with a reduction in long-term mortality or clinical outcomes. Future randomized trials are warranted to further evaluate the role of aspiration thrombectomy in select patients and coronary lesions.

SUBMITTER: Elgendy AY

PROVIDER: S-EPMC6490371 | biostudies-literature | 2017 Aug

REPOSITORIES: biostudies-literature

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Long-term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials.

Elgendy Akram Y AY Elgendy Islam Y IY Mahmoud Ahmed N AN Bavry Anthony A AA

Clinical cardiology 20170413 8

Randomized clinical trials that examined long-term clinical outcomes of routine aspiration thrombectomy prior to primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction have yielded different results. We hypothesized that the routine use of manual thrombus aspiration prior to primary PCI lacks long-term clinical benefits. Electronic databases were searched for randomized trials comparing routine aspiration thrombectomy and conventional P ...[more]

PMID: 28409835

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Project description:BackgroundPatients with peripheral arterial disease (PAD) have known to a high risk of cardiac mortality. However, the effectiveness of the routine evaluation of coronary arteries such as routine coronary angiography (CAG) in PAD patients receiving percutaneous transluminal angioplasty (PTA) is unclear.MethodsA total of 765 consecutive PAD patients underwent successful PTA and 674 patients (88.1%) underwent routine CAG. Coronary artery disease (CAD) was defined as angiographic stenosis ≥70%. Patients were divided into three groups; 1) routine CAG and a presence of CAD (n = 413 patients), 2) routine CAG and no CAD group (n = 261 patients), and 3) no CAG group (n = 91 patients). To adjust for any potential confounders that could cause bias, multivariable Cox-proportional hazards regression and propensity score matching (PSM) analysis was performed. Clinical outcomes were evaluated by Kaplan-Meier curved analysis at 5-year follow-up.ResultsIn this study, the 5-year survival rate of patients with PAD who underwent PTA was 88.5%. Survival rates were similar among the CAD group, the no CAD group, and the no CAG group, respectively (87.7% vs. 90.4% vs. 86.8% P = 0.241). After PSM analysis between the CAD group and the no CAD group, during the 5-year clinical follow-up, there were no differences in the incidence of death, myocardial infarction, strokes, peripheral revascularization, or target extremity surgeries between the two groups except for repeat PCI, which was higher in the CAD group than the non-CAD group (9.3% vs. 0.8%, P<0.001).ConclusionPAD patients with CAD were expected to have very poor long-term survival, but they are shown no different long-term prognosis such as mortality compared to PAD patients without CAD. These PAD patients with CAD had received PCI and/or optimal medication treatment after the CAG. Therefore a strategy of routine CAG and subsequent PCI, if required, appears to be a reasonable strategy for mortality risk reduction of PAD patients. Our results highlight the importance for evaluation for CAD in patients with PAD.

Project description:ImportanceFollowing negative randomized clinical trials, US guidelines downgraded support for routine manual aspiration thrombectomy (AT) during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). However, some PCI operators continue to endorse a clinical benefit with AT use despite the lack of supportive data.ObjectiveTo examine temporal trends and comparative outcomes of AT use during pPCI for STEMI.Design, setting, and participantsRetrospective cohort study of the National Cardiovascular Data Registry (NCDR) CathPCI Registry from July 1, 2009, to June 30, 2016, to assess temporal trends and in-hospital outcomes associated with AT use. To evaluate outcomes through 180 days, a subanalysis was conducted among Centers for Medicare and Medicaid Services-linked patients from July 1, 2009, through December 31, 2014. The comparative effectiveness analysis was performed using instrumental variable analyses to account for treatment selection bias. The instrumental variable was operator's preference to use AT during pPCI. Data were analyzed between February 1, 2017, and April 1, 2018.ExposuresAspiration thrombectomy use during pPCI for STEMI.Main outcomes and measuresPrimary outcomes included in-hospital stroke and death. Secondary outcomes included heart failure, stroke, all-cause rehospitalization, and death through 180 days of follow-up.ResultsAmong all pPCIs performed (683 584), the mean (SD) age of patients was 61.7 (12.8) years, 489 257 were male (71.6%), and 596 384 were white (87.2%). Among patients undergoing pPCI, AT use increased from 2009 through 2011, with peak use of 13.8%. This was followed by a decline of more than 9%, reaching 4.7% by mid-2016. Overall, AT was used in 10.8% of pPCIs (lowest operator group median, 0%; highest operator group median, 33.8%). After instrumental variable analysis, AT use was associated with no difference in in-hospital death (adjusted absolute risk difference, -0.18%; 95% CI, -0.53% to 0.16%; P = .29) and a small increase in in-hospital stroke (adjusted RD, 0.14%; 95% CI, 0.01%-0.30%; P = .03). Among Centers for Medicare and Medicaid Services-linked patients, AT use was not associated with differences in death, heart failure, stroke, or rehospitalization at 180 days.Conclusions and relevanceIn this large, nationwide analysis, AT use during STEMI pPCI declined by more than 50% since 2011, with use as of mid-2016 at less than 5%. Selective AT use was associated with a small excess risk of in-hospital stroke and no difference in other outcomes through 180 days of follow-up.

Project description:Objective:We aim to evaluate the long-term prognosis of non-ST elevation acute coronary syndrome (NSTE-ACS) patients with high-risk coronary anatomy (HRCA). Background:Coronary disease severity is important for therapeutic decision-making and prognostication among patients presenting with NSTE-ACS. However, long-term outcome in patients undergoing percutaneous coronary intervention (PCI) with HRCA is still unknown. Method:NSTE-ACS patients undergoing PCI in Fuwai Hospital in 2013 were prospectively enrolled and subsequently divided into HRCA and low-risk coronary anatomy (LRCA) groups according to whether angiography complies with the HRCA definition. HRCA was defined as left main disease >50%, proximal LAD lesion >70%, or 2- to 3- vessel disease involving the LAD. Prognosis impact on 2-year and 5-year major adverse cardiovascular and cerebrovascular events (MACCE) is analyzed. Results:Out of 4,984 enrolled patients with NSTE-ACS, 3,752 patients belonged to the HRCA group, while 1,232 patients belonged to the LRCA group. Compared with the LRCA group, patients in the HRCA group had worse baseline characteristics including higher age, more comorbidities, and worse angiographic findings. Patients in the HRCA group had higher incidence of unplanned revascularization (2 years: 9.7% vs. 5.1%, p < 0.001; 5 years: 15.4% vs. 10.3%, p < 0.001), 2-year MACCE (13.1% vs. 8.8%, p < 0.001), and 5-year death/MI/revascularization/stroke (23.0% vs. 18.4%, p = 0.001). Kaplan-Meier survival analysis showed similar results. After adjusting for confounding factors, HRCA is independently associated with higher risk of revascularization (2 years: HR?=?1.636, 95% CI: 1.225-2.186; 5 years: HR?=?1.460, 95% CI: 1.186-1.798), 2-year MACCE (HR?=?1.275, 95% CI?=?1.019-1.596) and 5-year death/MI/revascularization/stroke (HR?=?1.183, 95% CI: 1.010-1.385). Conclusion:In our large cohort of Chinese patients, HRCA is an independent risk factor for long-term unplanned revascularization and MACCE.

Project description:ImportanceData are lacking on the outcomes of patients with severely reduced left ventricular ejection fraction (LVEF) who undergo revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).ObjectiveTo compare the long-term outcomes in patients undergoing revascularization by PCI or CABG.Design, setting, and participantsThis retrospective cohort study performed in Ontario, Canada, from October 1, 2008, and December 31, 2016, included data from Ontario residents between 40 and 84 years of age with LVEFs less than 35% and left anterior descending (LAD), left main, or multivessel coronary artery disease (with or without LAD involvement) who underwent PCI or CABG. Exclusion criteria were concomitant procedures, previous CABG, metastatic cancer, dialysis, CABG and PCI on the same day, and emergency revascularization within 24 hours of a myocardial infarction (MI). Data analysis was performed from June 2, 2018, to December 28, 2018.ExposuresRevascularization by PCI or CABG.Main outcomes and measuresThe primary outcome was all-cause mortality. Secondary outcomes were death from cardiovascular disease, major adverse cardiovascular events (MACE; defined as stroke, subsequent revascularization, and hospitalization for MI or heart failure), and each of the individual MACE.ResultsA total of 12 113 patients (mean [SD] age, 64.8 (11.0) years for the PCI group and 65.6 [9.7] years for the CABG group; 5084 (72.5%) male for the PCI group and 4229 (82.9%) male for the PCI group) were propensity score matched on 30 baseline characteristics: 2397 patients undergoing PCI and 2397 patients undergoing CABG. The median follow-up was 5.2 years (interquartile range, 5.0-5.3). Patients who received PCI had significantly higher rates of mortality (hazard ratio [HR], 1.6; 95% CI, 1.3-1.7), death from cardiovascular disease (HR 1.4, 95% CI, 1.1-1.6), MACE (HR, 2.0; 95% CI, 1.9-2.2), subsequent revascularization (HR, 3.7; 95% CI, 3.2-4.3), and hospitalization for MI (HR, 3.2; 95% CI, 2.6-3.8) and heart failure (HR, 1.5; 95% CI, 1.3-1.6) compared with matched patients who underwent CABG.Conclusions and relevanceIn this study, higher rates of mortality and MACE were seen in patients who received PCI compared with those who underwent CABG. The findings may provide insight to physicians who are involved in decision-making for these patients.

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Long-term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials.

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Long-term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials.

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