Approach to large thrombus burden in ST-elevation myocardial infarction

In ST-Elevation Myocardial Infarction (STEMI), Primary Percutaneous Coronary Intervention (PPCI) is the preferred treatment. However, High Thrombus Burden (HTB), defined by extensive thrombus in the Infarct-Related Artery (IRA), particularly with "cut-off" occlusion patterns and large vessel diameter (>3.5 mm), presents a major challenge. Despite the use of effective anticoagulation, glycoprotein IIb/IIIa inhibitors, and Dual Antiplatelet Therapy (DAPT), HTB remains a significant obstacle. It is associated with complications such as no/slow reflow and distal embolization, leading to adverse cardiovascular outcomes. Accurate assessment using angiographic features and MI thrombus grading is essential before choosing a therapeutic strategy. Management options include mechanical thrombectomy, aspiration, parenteral/oral antiplatelets, intracoronary thrombolytics, and stenting approaches like direct stenting. Success depends on tailored, scenario-specific application of these therapies. This review highlights current strategies to manage HTB during PPCI.