Aspiration thrombectomy in 2015: a TOTAL defeat?

Primary percutaneous coronary intervention (pPCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI), but in a relevant proportion of cases it fails to achieve restoration of perfusion at the level of microcirculation, due to the “no reflow” phenomenon (1). Distal thrombotic embolization has a role among the mechanisms of no reflow, and intracoronary aspiration thrombectomy (AT) was conceived several years ago as an adjunct to pPCI to address this problem (2). Over the last 15 years, AT has been thoroughly investigated in clinical trials, but its clinical value is still debated. In fact, initial studies reported that routine use of AT impacted favourably on surrogate end points such as myocardial blush grade or ST-segment elevation resolution (STR) after pPCI; in addition, the randomized TAPAS trial (Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study), although not powered for clinical endpoints, reported a benefit on 1-year mortality (3,4). Therefore, the 2012 guidelines on STEMI of the European Society of Cardiology (ESC) stated that “routine AT should be considered” (class IIa recommendation) (5). However, the larger TASTE trial (Thrombus Aspiration in STEMI in Scandinavia) failed to prove a significant advantage of routine AT in terms of early and medium-term mortality (6,7), leading to a downgrade of AT to class IIb in 2014 ESC guidelines on myocardial revascularization (8). Most recently, the TOTAL trial (Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI), enrolling 10,732 patients, confirmed the lack of mortality benefit with routine AT (9).