Skip main navigation

Prognostic Role of Residual Thrombus Burden Following Thrombectomy: Insights From the TOTAL Trial

Originally published Cardiovascular Interventions. 2022;15


    It is unclear whether more effective forms of thrombus removal than current aspiration catheters would lead to improved outcomes. We sought to evaluate the prognostic role of residual thrombus burden (rTB), after manual thrombectomy, in patients undergoing primary percutaneous coronary intervention with routine manual thrombectomy in the TOTAL trial (Thrombectomy Versus PCI Alone).


    This is a single-arm analysis of patients from the TOTAL trial who underwent routine manual aspiration thrombectomy. The rTB was quantified by an angiographic core laboratory using the Thrombolysis in Myocardial Infarction criteria and validated using existing optical coherent tomography data. Large rTB was defined as grade ≥3. The primary outcome was death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or new or worsening heart failure within 180 days.


    Of 5033 patients randomized to routine thrombectomy, 2869 patients had quantifiable rTB (1014 [35%] had large rTB). Patients with large rTB were more likely to have hypertension, previous percutaneous coronary intervention, myocardial infarction, or Killip class III on presentation but less likely to have Killip class I. The primary outcome occurred more frequently in patients with large rTB, even after adjustment for known risk predictors (8.6% versus 4.6%; adjusted hazard ratio, 1.83 [95% CI, 1.34–2.48]). These patients also had a higher risk of cardiovascular death (adjusted hazard ratio, 1.83 [95% CI, 1.13–2.95]), cardiogenic shock (adjusted hazard ratio, 2.02 [95% CI, 1.08–3.76]), and heart failure (adjusted hazard ratio, 1.74 [95% CI, 1.02–2.96]) but not myocardial infarction or stroke.


    Large rTB is a common finding in primary percutaneous coronary intervention and is associated with increased risk of adverse cardiovascular outcomes, including cardiovascular death. Future technologies offering better thrombus removal than current devices may decrease or even eliminate the risk associated with rTB. This, potentially, can turn into a strategic option to be studied in clinical trials.


    URL:; Unique identifier: NCT01149044.


    This manuscript was sent to Subhash Banerjee, MD, Deputy Editor, for review by expert referees, editorial decision, and final disposition.

    Supplemental Material is available at

    For Sources of Funding and Disclosures, see page 413.

    Correspondence to: Vladimír Džavík, MD, FAHA, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, 6-246A EN, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4, Email
    Mohammad Alkhalil, MRCP, DPhil, Peter Munk Cardiac Centre, University Health Network, Toronto General Hospital, 6-246A EN, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4, Email


    • 1. Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ, Kedev S, Thabane L, Stankovic G, Moreno R, et al.; TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy.N Engl J Med. 2015; 372:1389–1398. doi: 10.1056/NEJMoa1415098CrossrefMedlineGoogle Scholar
    • 2. Jolly SS, James S, Džavík V, Cairns JA, Mahmoud KD, Zijlstra F, Yusuf S, Olivecrona GK, Renlund H, Gao P, et al.. Thrombus aspiration in ST-segment-elevation myocardial infarction: an individual patient meta-analysis: thrombectomy trialists collaboration.Circulation. 2017; 135:143–152. doi: 10.1161/CIRCULATIONAHA.116.025371LinkGoogle Scholar
    • 3. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, et al.; ESC Scientific Document Group. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2018; 39:119–177. doi: 10.1093/eurheartj/ehx393CrossrefMedlineGoogle Scholar
    • 4. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, et al.; Endorsed by the Latin American Society of Interventional Cardiology; PCI Writing Committee. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American college of cardiology/American heart association task force on clinical practice guidelines and the society for cardiovascular angiography and interventions.Circulation. 2016; 133:1135–1147. doi: 10.1161/CIR.0000000000000336LinkGoogle Scholar
    • 5. Bhindi R, Kajander OA, Jolly SS, Kassam S, Lavi S, Niemelä K, Fung A, Cheema AN, Meeks B, Alexopoulos D, et al.. Culprit lesion thrombus burden after manual thrombectomy or percutaneous coronary intervention-alone in ST-segment elevation myocardial infarction: the optical coherence tomography sub-study of the TOTAL (Thrombectomy Versus PCI Alone) trial.Eur Heart J. 2015; 36:1892–1900. doi: 10.1093/eurheartj/ehv176CrossrefMedlineGoogle Scholar
    • 6. Topaz O. Cardiovascular Thrombus: From Pathology and Clinical Presentations To Imaging, Pharmacotherapy and Interventions. Elsevier; 2018.Google Scholar
    • 7. Gibson CM, de Lemos JA, Murphy SA, Marble SJ, McCabe CH, Cannon CP, Antman EM, Braunwald E; TIMI Study Group. Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: a TIMI 14 substudy.Circulation. 2001; 103:2550–2554. doi: 10.1161/01.cir.103.21.2550CrossrefMedlineGoogle Scholar
    • 8. Higuma T, Soeda T, Yamada M, Yokota T, Yokoyama H, Izumiyama K, Nishizaki F, Minami Y, Xing L, Yamamoto E, et al.. Does residual thrombus after aspiration thrombectomy affect the outcome of primary PCI in patients with st-segment elevation myocardial infarction? An optical coherence tomography study.JACC Cardiovasc Interv. 2016; 9:2002–2011. doi: 10.1016/j.jcin.2016.06.050CrossrefMedlineGoogle Scholar
    • 9. Topaz O. The inconsistency of manual thrombectomy and the role of contemporary thrombus grading in PCI for STEMI.Catheter Cardiovasc Interv. 2021; 97:1149–1150. doi: 10.1002/ccd.29732CrossrefMedlineGoogle Scholar
    • 10. De Maria GL, Fahrni G, Alkhalil M, Cuculi F, Dawkins S, Wolfrum M, Choudhury RP, Forfar JC, Prendergast BD, Yetgin T, et al.. A tool for predicting the outcome of reperfusion in ST-elevation myocardial infarction using age, thrombotic burden and index of microcirculatory resistance (ATI score).EuroIntervention. 2016; 12:1223–1230. doi: 10.4244/EIJV12I10A202CrossrefMedlineGoogle Scholar
    • 11. De Maria GL, Alkhalil M, Wolfrum M, Fahrni G, Borlotti A, Gaughran L, Dawkins S, Langrish JP, Lucking AJ, Choudhury RP, et al.. The ATI score (age-thrombus burden-index of microcirculatory resistance) determined during primary percutaneous coronary intervention predicts final infarct size in patients with ST-elevation myocardial infarction: a cardiac magnetic resonance validation study.EuroIntervention. 2017; 13:935–943. doi: 10.4244/EIJ-D-17-00367MedlineGoogle Scholar
    • 12. Sharma V, Jolly SS, Hamid T, Sharma D, Chiha J, Chan W, Fuchs F, Bui S, Gao P, Kassam S, et al.. Myocardial blush and microvascular reperfusion following manual thrombectomy during percutaneous coronary intervention for ST elevation myocardial infarction: insights from the TOTAL trial.Eur Heart J. 2016; 37:1891–1898. doi: 10.1093/eurheartj/ehw157CrossrefMedlineGoogle Scholar
    • 13. Cantor WJ, Madan M, O’Shea JC, Chisholm RJ, Lui HK, Cohen DJ, Feldman RL, Green R, Hellkamp AS, Kitt MM, et al.. Bailout use of platelet glycoprotein IIb-IIIa inhibition during coronary stent implantation: observations from the ESPRIT trial.J Invasive Cardiol. 2005; 17:360–364.MedlineGoogle Scholar
    • 14. Farooq V, Serruys PW, Mustafa AH, Mamas MA, Malik N, Alhous HA, El-Omar M, Hendry C, Rana DN, Shelton D, et al.. Forward and back aspiration during ST-elevation myocardial infarction: a feasibility study.EuroIntervention. 2016; 11:e1639–e1648. doi: 10.4244/EIJV11I14A315CrossrefMedlineGoogle Scholar
    • 15. Parodi G, Valenti R, Migliorini A, Maehara A, Vergara R, Carrabba N, Mintz GS, Antoniucci D. Comparison of manual thrombus aspiration with rheolytic thrombectomy in acute myocardial infarction.Circ Cardiovasc Interv. 2013; 6:224–230. doi: 10.1161/CIRCINTERVENTIONS.112.000172LinkGoogle Scholar
    • 16. Ali A, Cox D, Dib N, Brodie B, Berman D, Gupta N, Browne K, Iwaoka R, Azrin M, Stapleton D, et al.; AIMI Investigators. Rheolytic thrombectomy with percutaneous coronary intervention for infarct size reduction in acute myocardial infarction: 30-day results from a multicenter randomized study.J Am Coll Cardiol. 2006; 48:244–252. doi: 10.1016/j.jacc.2006.03.044CrossrefMedlineGoogle Scholar
    • 17. Topaz O, Ebersole D, Das T, Alderman EL, Madyoon H, Vora K, Baker JD, Hilton D, Dahm JB; CARMEL Multicenter Trial. Excimer laser angioplasty in acute myocardial infarction (the CARMEL multicenter trial).Am J Cardiol. 2004; 93:694–701. doi: 10.1016/j.amjcard.2003.11.050CrossrefMedlineGoogle Scholar
    • 18. Topaz O. Plaque removal and thrombus dissolution with the photoacoustic energy of pulsed-wave lasers-biotissue interactions and their clinical manifestations.Cardiology. 1996; 87:384–391. doi: 10.1159/000177125CrossrefMedlineGoogle Scholar
    • 19. Topaz O, Minisi AJ, Bernardo NL, McPherson RA, Martin E, Carr SL, Carr ME. Alterations of platelet aggregation kinetics with ultraviolet laser emission: the “stunned platelet” phenomenon.Thromb Haemost. 2001; 86:1087–1093.CrossrefMedlineGoogle Scholar