Thrombectomy and target vessel protection during PCI

Background

Prevention and management of coronary embolism is one of the greatest challenges during percutaneous coronary interventions (PCI), aiming at preserving microvascular integrity to warrant successful myocardial reperfusion.

Embolization can occur both in the context of Acute Coronary Syndromes (ACS), where large thrombus burden carries a twofold increase in mortality and a two-to-fourfold risk of major cardiovascular events, and during interventions on stable Coronary Artery Disease (CAD), where it's usually due to plaque iatrogenic fragmentation. Whatever the underlying mechanism and the interventional context, embolization has been shown to impair clinical outcomes by affecting microvascular patency.

Strategies to prevent these consequences have been theorized in the last decades. Thrombus debulking before conventional PCI in ACS achieved controversial results in clinical trials. As a consequence, aspiration thrombectomy in myocardial infarction has been downgraded in recommendations provided by European and American guidelines. By contrast, in the context of saphenous vein graft PCI protection devices have granted favorable results and are nowadays strongly supported.

In this chapter we review some of the pathophysiological mechanisms relating embolic phenomena to clinical outcomes and provide an overview on currently available thrombectomy and protection systems, with a glance on future perspectives for the prevention and management of embolic...