Focus on the infarct‐related artery: A thrombus runs through it

Thrombi are commonly found in patients with acute ischemic coronary syndromes such as acute MI and USA [1]. Thrombi are also accountable for pathophysiologic processes involved in peripheral vascular ischemic syndromes. Indeed, relevant literature describing percutaneous coronary intervention (PCI) techniques for debulking of thrombotic lesions spanning the last 2 decades is available for the interested interventionalist. The focus on thrombus within PCI stems from a longstanding realization and repeated experiences demonstrating the association between presence of intracoronary thrombus with an increased complication incidence during and after percutaneous intervention [2]. To be specific, many share the opinion that the real challenge in PCI is the thrombus, and to a much higher degree than the underlying plaque [3]. Brittle in structure, ever ready to accumulate aggressively, prone to embolization, easy to produce no-reflow phenomenon, and frequently resisting removal, the thrombus stands as an obstacle along the way of achieving PCI success. Acute revascularization of the infarct-related artery basically consists of three major strategies: pharmacologic agents, mechanical devices, and a combined approach termed “power thrombectomy” [4]. The word power denotes enhanced or synergistic effect of mechanical forces on activity of a pharmacologic drug. In regard to the first strategy, it is clear that the limitations of the pharmacologic treatment, i.e., the angiographic ceiling, which leads to thrombolysis and adequate antegrade reperfusion in only 50%–60% of treated patients, are here to stay. Furthermore, there is a growing recognition that in the presence of angiographic thrombus, IIb/IIIa receptor antagonists have no positive impact on PCI results [5]. This plays a major role in the rejuvenated interest of mechanical removal of the offending thrombus. In the present issue, Wang et al. [6] from the National Taiwan University Hospital describe their early experience with the Export Aspiration Catheter (EAC) in 12 patients with acute MI. Primary mechanical thrombus removal from the target lesion within the infarct-related artery was performed before balloon and/or stent were applied. In 9/12 patients, macroscopic thrombotic material was found in the aspirated blood. Each procedure was successful, resulting in a final TIMI 3 flow. There were no in-hospital complications. To begin with, the authors are to be commended for their approach to mechanical reduction of thrombus burden in acute MI and for gaining adequate clinical outcomes; however, analysis of the report reveals several points of concern. First, the vessels treated did not include any saphenous vein grafts, conduits notoriously more difficult to revascularize than native coronary arteries. Another concern relates to the fact that EAC-induced TIMI 3 flow was achieved in only 7 (58%) of the 12 treated patients, 2 of whom already had that degree of antegrade flow prior to the activation of the EAC. In fact, such a limited restoration of adequate antegrade flow offers no significant advantage over that of pharmacologic agent. Thirdly, no patient was hemodynamically unstable or in cardiogenic shock. Thus, this series represents relatively stable patients who are less challenging AMI cases. Moreover, it is clear that the EAC device is capable of thrombus reduction in proximal lesions, however, its yield in distal coronary and graft lesions is yet unknown. The authors, understandably so, dedicated most of their discussion to the merits of the EAC device and its activation technique. Other mechanical modalities used for the same purpose, such as ultrasound [7], Angiojet [8], laser [9], and TEC [10] are scarcely mentioned. Although these devices are mostly used by high-volume, experienced interventionalists, and although they are not perfect tools, they do have a proven, documented record of success in complex thrombotic lesions and hemodynamically compromised patients. Experienced interventionalists will be at odds with the authors’ assertion that Angiojet, laser, or ultrasound catheters are less trackable than the EAC. Utilizing adequate guiding catheters and guidewire support, the TEC catheter is also not difficult to track. Conceivably, due to their relatively large size and mechanics, these traditional devices can aspirate a larger thrombus volume and therefore achieve im-