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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e54 CLINICAL STATEMENTS AND GUIDELINES outcomes in patients with OCT-guided PCI versus angiography-guided PCI.11 3. A combination of stent-, procedure-, and patientrelated factors are involved in the pathophysiology of stent thrombosis or restenosis.14,27 Early stent thrombosis is more commonly a result of residual target-lesion thrombus, stent failure, or nonadherence to DAPT, whereas late stent thrombosis is associated with inadequate neointimal coverage or incomplete healing. Assessment of the cause of stent thrombosis with intracoronary imaging is important to guide subsequent treatment. Similarly, advanced imaging techniques have an important role in detecting underlying mechanical and pathophysiological factors that contribute to in-stent restenosis (ISR), such as neointimal hyperplasia, stent underexpansion, and fractures.14,15 Detailed intrastent visualization allows new possibilities for tissue characterization and may help better identify patients at risk of ISR.28 Registry and case series data have demonstrated that IVUS and OCT can be useful for evaluating the mechanisms of stent restenosis and stent thrombosis.16,17,29,30 OCT is better at differentiating between stent-related mechanisms, whereas IVUS is preferred for indepth vessel wall characterization.30,31 10.4 Thrombectomy Recommendation for Thrombectomy Referenced studies that support the recommendation are summarized in Online Data Supplement 26. COR LOE Recommendation 3: No Benefit A 1. In patients with STEMI, routine aspiration thrombectomy before primary PCI is not useful.1-5 Synopsis Many patients with STEMI will have thrombotic occlusion of the infarct artery on the initial angiogram. Therefore, it is natural to consider the use of a device that would decrease thrombus burden to decrease the risk of distal embolization and the no-reflow phenomenon. However, patients in trials with STEMI undergoing primary PCI did not derive any clinical benefit from routine rheolytic thrombectomy.6,7 Additionally, although the initial studies of aspiration thrombectomy in STEMI demonstrated an improvement in myocardial blush grades and rates of ST-segment–elevation resolution,8-10 larger studies have not demonstrated improved cardiovascular outcomes with thrombus aspiration.1-5 Recommendation-Specific Supporting Text 1. Patients enrolled in contemporary trials did not derive a benefit of reduction in infarct size5 or improvement in death, reinfarction, stent thrombosis, or target-lesion revascularization at 30 days or 1 year1,4 or cardiovascular death, recurrent MI, cardiogenic shock, or NYHA Class IV heart failure at 3 months or 1 year2,3 with aspiration thrombectomy compared with routine stenting. In the TOTAL (Thrombectomy with PCI vs. PCI Alone in patients with STEMI) trial, patients who were assigned to aspiration thrombectomy were found to have a small but statistically significant increased risk of stroke.2,3 A patient-level meta-analysis found no significant reduction in cardiovascular death at 30 days with routine aspiration thrombectomy but did find a trend toward a higher rate of stroke.11 Moreover, in the subgroup of patients with high thrombus burden, thrombus aspiration was associated with a small but statistically significant reduced rate of cardiovascular death and a small but statistically significant increased rate of stroke. For this reason, additional dedicated studies focusing on the selective use of thrombus aspiration in patients with high thrombus burden are needed. 10.5 Treatment of Calcified Lesions Recommendations for the Treatment of Calcified Lesions Referenced studies that support the recommendations are summarized in Online Data Supplement 27. COR LOE Recommendations 2a B-R 1. In patients with fibrotic or heavily calcified lesions, plaque modification with rotational atherectomy can be useful to improve procedural success.1-3 2b B-NR 2. In patients with fibrotic or heavily calcified lesions, plaque modification with orbital atherectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy may be considered to improve procedural success.4-8 Synopsis Fibrotic or heavily calcified lesions can hinder stent expansion. The presence of calcium deposits thicker than 500 μm or calcium involving an arc of the vessel >270° on intravascular imaging predicts the need for lesion modification to facilitate stent delivery.9 Lesions can be modified by using rotational atherectomy, orbital atherectomy, cutting balloon atherotomy, intracoronary lithotripsy, or excimer laser angioplasty. Despite promising results from hundreds of small mechanistic studies, dozens of large, randomized trials have shown that the routine use of atheroablative devices does not improve clinical or angiographic outcomes.1-3,10 However, the use of atheroablative devices may enhance procedural success in specific circumstances. Recommendation-Specific Supportive Text 1. Rotational atherectomy excavates inelastic atherosclerotic tissue through the use of a diamond-tipped Downloaded from http://ahajournals.org by on October 7, 2026