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Thrombectomy: beneficial (if ever) only in highly selected patients

Thrombectomy: beneficial (if ever) only in highly selected patients. Prof. Imad Sheiban University of Turin, Turin, Italy. CASE STUDY: ANTERIOR STEMI baseline angio. CASE STUDY: ANTERIOR STEMI wiring and predilation with NC balloon at 30 ATM.

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Thrombectomy: beneficial (if ever) only in highly selected patients

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  1. Thrombectomy: beneficial (if ever) only in highly selected patients Prof. Imad Sheiban University of Turin, Turin, Italy

  2. CASE STUDY: ANTERIOR STEMIbaselineangio

  3. CASE STUDY: ANTERIOR STEMIwiring and predilationwith NC balloon at 30 ATM undilatable and calcific culprit lesion: 2 NC Mercury 2.5x10 balloons had to be burst@30 ATM to open it

  4. CASE STUDY: ANTERIOR STEMIfinalresultafter stenting 2 BMS (3.0x18 @ 18 ATM and 2.75x28 @16 ATM)

  5. CASE STUDY: ANTERIOR STEMIfinalresultafter stenting WHAT IS THE ROLE OF THROMBECTOMY IN SUCH A PATIENT? NONE 2 BMS (3.0x18 @ 18 ATM and 2.75x28 @16 ATM)

  6. FANCY DEVICES ROUTINELY USEFUL OR POINTLESS BUT IN HIGHLY SELECTED PATIENTS?

  7. THE REMEDIA TRIAL Burzotta et al, JACC 2005

  8. THE REMEDIA TRIAL No data on device-related dissections. Failure to deliver Diver CE: 1/48. Cross-over to no thrombectomy: 2/48. Burzotta et al, JACC 2005

  9. THE DEAR-MI TRIAL Silva-Orrego et al, JACC 2006

  10. THE DEAR-MI TRIAL Failure to deliver Pronto: 12/74 Silva-Orrego et al, JACC 2006

  11. THE TAPAS TRIAL

  12. THE TAPAS TRIAL No device-related dissections despite inclusion of 500 patients. (???) No data on failure to deliver Export. Cross-over to no thrombectomy: 54/502. Svilaas et al, NEJM 2008

  13. THE TAPAS TRIAL Vlaar et al, Lancet 2008

  14. THE TAPAS TRIAL • Can webelievethis impact on survival? • Guessnot: • stentswereneverprovencapableofimprovingsurvival in STEMI; • itusuallytakesmuch >1000 ptsto prove mortality benefit in STEMI (e.g. GISSI enrolled 16000 ptsto prove thrombolysiswasbetterthan placebo). Vlaar et al, Lancet 2008

  15. WHAT ABOUT ANGIOJET? NO WAY! AiMI trial – 480 patients with STEMI

  16. ANY SYNTHESIS POSSIBLE?

  17. ANY SYNTHESIS POSSIBLE? Burzotta et al, EHJ 2009

  18. ANY SYNTHESIS POSSIBLE? All survival benefit driven only by TAPAS trial Burzotta et al, EHJ 2009

  19. CAN WE CONCLUDE SO FAR THAT ROUTINE THROMBECTOMY IS BENEFICIAL?

  20. CAN WE CONCLUDE SO FAR THAT ROUTINE THROMBECTOMY IS BENEFICIAL?VERDICT death ↑

  21. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESSbaseline angio in acutely occluded SVG

  22. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESSangio after guidewire crossing

  23. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESSthrombectomy with 6 Fr Diver CE

  24. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESSthrombectomy with 6 Fr Diver CE

  25. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESSfinal results after DES implantation 3.5x23 mm DES @ 18 ATM

  26. TAKE HOME MESSAGES • Active thrombectomy is too expensive and not risk-beneficial and thus should be discouraged in most cases • Manual thrombectomy can be attempted in selected cases with large thrombus burden in proximal lesions were lack of support or risk of dissection are not major issues • Most cases of STEMI can be managed with a highly selective use of manual thrombectomy, keeping balloon and stenting as the procedural workhorses

  27. Thank you for your attentionFor these and further slides on these topics feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

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