title: Forward and back aspiration during ST-elevation myocardial infarction: a feasibility study.
abstract: OBJECTIVE
  The inability to optimise stent expansion fully whilst simultaneously preventing distal embolisation during ST-elevation myocardial infarction (STEMI) remains a clinical conundrum. We aimed to describe a newly devised angiographic strategy of "forward" and "back" aspiration that leads to more complete thrombus removal and prevention of distal embolisation, to allow high-pressure post-dilatation of the implanted stent to be performed.
  
  
  RESULTS
  Forward aspiration was conducted with a conventional aspiration thrombectomy catheter, with bail-out aspiration thrombectomy for angiographically persistent thrombus utilising the larger bore 6 Fr (0.056") guide catheter extension system (GuideLiner; Vascular Solutions, Inc., Minneapolis, MN, USA). Back aspiration was undertaken with a deeply intubated GuideLiner or guide catheter with a vacuum induced within, extending to the inflated angioplasty balloon, to allow for proximal embolic protection during balloon deflation during all stages of the PCI procedure, including high-pressure post-dilatation of the stent to the visually estimated reference vessel diameter (RVD). Over a six-month period 30 consecutive cases were undertaken during working hours. Bail-out GuideLiner-assisted aspiration thrombectomy was performed in 9/30 cases because of inadequate thrombus removal with a conventional aspiration thrombectomy catheter. Back aspiration was performed in all cases. In 27/30 cases high-pressure post-dilatation of the stent was performed. The mean maximum post-dilatation balloon size and mean proximal reference vessel diameter did not significantly differ (3.60±0.41 mm vs. 3.65±0.45 mm, p=0.68). In all cases, implantation +/- post-dilatation of the stent to the visually estimated RVD was achievable without any deterioration in TIMI blood flow or myocardial blush grade.
  
  
  CONCLUSIONS
  The strategy of forward and back aspiration to facilitate stent implantation and high-pressure post-dilatation during STEMI appears to be safe and effective. Randomised controlled trials are required to confirm the safety and efficacy of this newly devised angiographic strategy.
authors.affiliation: Institute of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester and Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom.
authors.forename: Vasim
authors.initials: V
authors.lastname: Farooq
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.forename: Ahmad H S
authors.initials: AH
authors.lastname: Mustafa
authors.forename: Mamas A
authors.initials: MA
authors.lastname: Mamas
authors.forename: Nadim
authors.initials: N
authors.lastname: Malik
authors.forename: Hafez A
authors.initials: HA
authors.lastname: Alhous
authors.forename: Magdi
authors.initials: M
authors.lastname: El-Omar
authors.forename: Cara
authors.initials: C
authors.lastname: Hendry
authors.forename: Durgesh N
authors.initials: DN
authors.lastname: Rana
authors.forename: David
authors.initials: D
authors.lastname: Shelton
authors.forename: Paul K
authors.initials: PK
authors.lastname: Wright
authors.forename: Nadira
authors.initials: N
authors.lastname: Narine
authors.forename: Bernard
authors.initials: B
authors.lastname: Clarke
authors.forename: Bernard
authors.initials: B
authors.lastname: Keavney
authors.forename: Farzin
authors.initials: F
authors.lastname: Fath-Ordoubadi
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Fraser
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography / Q000379:methods; D003326:Coronary Circulation / Q000502:physiology; D003328:Coronary Thrombosis / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000072657:ST Elevation Myocardial Infarction / Q000601:surgery*; D013396:Suction / Q000379:methods; D017131:Thrombectomy / Q000379:methods; D016896:Treatment Outcome