Abstract
Routine use of distal protection for ST-segment elevation myocardial infarction (STEMI) is not recommended. The purpose of this study was to analyze the impact of slow flow on mortality after STEMI, and the efficacy of adjunctive distal protection following primary thrombus aspiration. We retrospectively analyzed 414 STEMI patients who underwent primary PCI. Distal protection was used following primary thrombus aspiration only when the operator judged the patient to be at high risk of slow flow. Patients were divided into 3 groups: those receiving no thrombus aspiration (A− Group), thrombus aspiration without distal protection (A+/D− Group) or a combination of aspiration with distal protection (A+/D+ Group). Slow flow/no reflow was characterized as transient or persistent. The A−, A+/D−, and A+/D+ Groups consisted of 28.5 % (n = 118), 44.4 % (n = 184), and 27.1 % (n = 112) of patients, respectively. All-cause mortality at 180 days was 6.8 % without slow flow, 14.1 % with transient and 44.4 % with persistent slow flow (P < 0.0001), but was similar whether or not distal protection was used among these groups complicated without slow flow (A−, 8.7 %; A+/D−, 6.3 %; A+/D+, 4.3 %; P = 0.5854). However, in cases complicated with transient or persistent slow flow, distal protection reduced all-cause mortality to 38.5 % (A−), 23.3 % (A+/D−), and 10.8 % (A+/D+) at 180 days (P = 0.0114). Our data confirm that routine distal protection is not to be recommended. However, it is suggested that it could reduce mortality of patients with slow flow. Predicting slow flow accurately before PCI, however, remains a challenge.
Similar content being viewed by others
References
Gibson CM, Cannon CP, Daley WL, Dodge JT Jr, Alexander B Jr, Marble SJ, et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation. 1996;93:879–88.
Simes RJ, Topol EJ, Holmes DR Jr, White HD, Rutsch WR, Vahanian A, et al. Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion. Importance of early and complete infarct artery reperfusion. Gusto-i investigators. Circulation. 1995;91:1923–8.
Morishima I, Sone T, Okumura K, Tsuboi H, Kondo J, Mukawa H, et al. Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction. J Am Coll Cardiol. 2000;36:1202–9.
Henriques JP, Zijlstra F, Ottervanger JP, de Boer MJ, van‘t Hof AW, Hoorntje JC, et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J. 2002;23:1112–1117.
Fokkema ML, Vlaar PJ, Svilaas T, Vogelzang M, Amo D, Diercks GF, et al. Incidence and clinical consequences of distal embolization on the coronary angiogram after percutaneous coronary intervention for ST-elevation myocardial infarction. Eur Heart J. 2009;30:908–15.
Dong-bao L, Qi H, Zhi L, Shan W, Wei-ying J. Predictors and short-term prognosis of angiographically detected distal embolization after emergency percutaneous coronary intervention for ST-elevation acute myocardial infarction. Clin Res Cardiol. 2009;98:773–9.
Ndrepepa G, Tiroch K, Keta D, Fusaro M, Seyfarth M, Pache J, et al. Predictive factors and impact of no reflow after primary percutaneous coronary intervention in patients with acute myocardial infarction. Circ Cardiovasc Interv. 2010;3:27–33.
Ndrepepa G, Tiroch K, Fusaro M, Keta D, Seyfarth M, Byrne RA, et al. 5-year prognostic value of no-reflow phenomenon after percutaneous coronary intervention in patients with acute myocardial infarction. J Am Coll Cardiol. 2010;55:2383–9.
Dong-bao L, Qi H, Zhi L, Shan W, Wei-ying J. Predictors and long-term prognosis of angiographic slow/no-reflow phenomenon during emergency percutaneous coronary intervention for ST-elevated acute myocardial infarction. Clin Cardiol. 2010;33:E7–12.
Chan W, Stub D, Clark DJ, Ajani AE, Andrianopoulos N, Brennan AL, et al. Usefulness of transient and persistent no reflow to predict adverse clinical outcomes following percutaneous coronary intervention. Am J Cardiol. 2012;109:478–85.
Limbruno U, Micheli A, De Carlo M, Amoroso G, Rossini R, Palagi C, et al. Mechanical prevention of distal embolization during primary angioplasty: safety, feasibility, and impact on myocardial reperfusion. Circulation. 2003;108:171–6.
Yip HK, Wu CJ, Chang HW, Fang CY, Yang CH, Chen SM, et al. Effect of the percusurge guardwire device on the integrity of microvasculature and clinical outcomes during primary transradial coronary intervention in acute myocardial infarction. Am J Cardiol. 2003;92:1331–5.
Stone GW, Webb J, Cox DA, Brodie BR, Qureshi M, Kalynych A, et al. Distal microcirculatory protection during percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: a randomized controlled trial. JAMA. 2005;293:1063–72.
Gick M, Jander N, Bestehorn HP, Kienzle RP, Ferenc M, Werner K, et al. Randomized evaluation of the effects of filter-based distal protection on myocardial perfusion and infarct size after primary percutaneous catheter intervention in myocardial infarction with and without ST-segment elevation. Circulation. 2005;112:1462–9.
Bartorelli AL, Koh TH, Di Pede F, Reimers B, Thuesen L, Amann FW, et al. Distal embolic protection during percutaneous coronary intervention in patients with acute coronary syndromes: the RUBY study. Acute Card Care. 2006;8:148–54.
Kaltoft A, Bottcher M, Nielsen SS, Hansen HH, Terkelsen C, Maeng M, et al. Routine thrombectomy in percutaneous coronary intervention for acute ST-segment-elevation myocardial infarction: a randomized, controlled trial. Circulation. 2006;114:40–7.
Cura FA, Escudero AG, Berrocal D, Mendiz O, Trivi MS, Fernandez J, et al. Protection of distal embolization in high-risk patients with acute ST-segment elevation myocardial infarction (PREMIAR). Am J Cardiol. 2007;99:357–63.
Zhou BQ, Tahk SJ. Effect of a distal protection device on epicardial blood flow and myocardial perfusion in primary percutaneous coronary intervention. J Zhejiang Univ Sci B. 2007;8:575–9.
Muramatsu T, Kozuma K, Tsukahara R, Ito Y, Fujita N, Suwa S, et al. Comparison of myocardial perfusion by distal protection before and after primary stenting for acute myocardial infarction: angiographic and clinical results of a randomized controlled trial. Catheter Cardiovasc Interv. 2007;70:677–82.
Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta-analysis of randomized trials. Eur Heart J. 2008;29:2989–3001.
Mamas MA, Fraser D, Fath-Ordoubadi F. The role of thrombectomy and distal protection devices during percutaneous coronary interventions. EuroIntervention. 2008;4:115–23.
Kelbaek H, Terkelsen CJ, Helqvist S, Lassen JF, Clemmensen P, Klovgaard L, et al. Randomized comparison of distal protection versus conventional treatment in primary percutaneous coronary intervention: the drug elution and distal protection in st-elevation myocardial infarction (DEDICATION) trial. J Am Coll Cardiol. 2008;51:899–905.
Kaltoft A, Nielsen SS, Terkelsen CJ, Bottcher M, Lassen JF, Krusell LR, et al. Scintigraphic evaluation of routine filterwire distal protection in percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: a randomized controlled trial. J Nucl Cardiol. 2009;16:784–91.
Jin B, Dong XH, Zhang C, Li Y, Shi HM. Distal protection devices in primary percutaneous coronary intervention of native coronary artery lesions: a meta-analysis of randomized controlled trials. Curr Med Res Opin. 2012;28:871–6.
Ikari Y, Sakurada M, Kozuma K, Kawano S, Katsuki T, Kimura K, et al. Upfront thrombus aspiration in primary coronary intervention for patients with st-segment elevation acute myocardial infarction: report of the vampire (VAcuuM asPIration thrombus REmoval) trial. JACC Cardiovasc Interv. 2008;1:424–31.
Lefevre T, Garcia E, Reimers B, Lang I, di Mario C, Colombo A, et al. X-sizer for thrombectomy in acute myocardial infarction improves ST-segment resolution: results of the x-sizer in ami for negligible embolization and optimal st resolution (X AMINE ST) trial. J Am Coll Cardiol. 2005;46:246–52.
Vlaar PJ, Svilaas T, van der Horst IC, Diercks GF, Fokkema ML, de Smet BJ, et al. Cardiac death and reinfarction after 1 year in the thrombus aspiration during percutaneous coronary intervention in acute myocardial infarction study (TAPAS): a 1-year follow-up study. Lancet. 2008;371:1915–20.
Srinivasan M, Rihal C, Holmes DR, Prasad A. Adjunctive thrombectomy and distal protection in primary percutaneous coronary intervention: impact on microvascular perfusion and outcomes. Circulation. 2009;119:1311–9.
Isshiki T, Kozuma K, Kyono H, Suzuki N, Yokoyama N, Yamamoto Y. Initial clinical experience with distal embolic protection using “filtrap”, a novel filter device with a self-expandable spiral basket in patients undergoing percutaneous coronary intervention. Cardiovasc Interv Ther. 2011;26:12.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third universal definition of myocardial infarction. Circulation. 2012;126:2020–35.
Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, et al. Thrombolysis in myocardial infarction (TIMI) trial, phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987;76:142–54.
Topol EJ, Yadav JS. Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation. 2000;101:570–80.
Gorog DA, Foale RA, Malik I. Distal myocardial protection during percutaneous coronary intervention: when and where? J Am Coll Cardiol. 2005;46:1434–45.
Ito H. The no-reflow phenomenon associated with percutaneous coronary intervention: Its mechanisms and treatment. Cardiovasc Interv Ther. 2011;26:2.
Stone GW, Rogers C, Hermiller J, Feldman R, Hall P, Haber R, et al. Randomized comparison of distal protection with a filter-based catheter and a balloon occlusion and aspiration system during percutaneous intervention of diseased saphenous vein aorto-coronary bypass grafts. Circulation. 2003;108:548–53.
Matsuo A, Inoue N, Suzuki K, Nakamura R, Fujita H, Miki S, et al. Limitations of using a guardwire temporary occlusion and aspiration system in patients with acute myocardial infarction: multicenter investigation of coronary artery protection with a distal occlusion device in acute myocardial infarction (MICADO). J Invasive Cardiol. 2007;19:132–8.
Limbruno U, De Caterina R. EMERALD, AIMI, and PROMISE: is there still a potential for embolic protection in primary PCI? Eur Heart J. 2006;27:1139–45.
Svilaas T, Vlaar PJ, van der Horst IC, Diercks GF, de Smet BJ, van den Heuvel AF, et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med. 2008;358:557–67.
Jang IK, Tearney GJ, MacNeill B, Takano M, Moselewski F, Iftima N, et al. In vivo characterization of coronary atherosclerotic plaque by use of optical coherence tomography. Circulation. 2005;111:1551–5.
Endo M, Hibi K, Shimizu T, Komura N, Kusama I, Otsuka F, et al. Impact of ultrasound attenuation and plaque rupture as detected by intravascular ultrasound on the incidence of no-reflow phenomenon after percutaneous coronary intervention in ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2010;3:540–9.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Fujii, T., Masuda, N., Nakano, M. et al. Impact of transient or persistent slow flow and adjunctive distal protection on mortality in ST-segment elevation myocardial infarction. Cardiovasc Interv and Ther 30, 121–130 (2015). https://doi.org/10.1007/s12928-014-0295-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12928-014-0295-z