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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e811 STEMI) demonstrated that radial access was independently associated with a significant 24% and 51% relative risk reduction of all-cause death and major bleeding, respectively, when compared with femoral access.3 The magnitude of the mortality benefit was greater among patients with lower baseline hemoglobin levels. The benefit of radial access toward reducing bleeding was driven by a significant reduction in access-site bleeding. Vascular complications were significantly reduced by 62%. The MATRIX trial6 demonstrated a significantly lower rate of the coprimary endpoints of MACE and net adverse clinical events (composites of death, MI, and stroke at 30 days, and MACE plus non-CABG major bleeding) among patients with ACS randomized to the transradial approach compared with the transfemoral approach. This is consistent with prior meta-analyses that have reported lower mortality and bleeding with radial access in patients with ACS.4,14 The SAFARI-STEMI (Safety and Efficacy of Femoral Access versus Radial for Primary Percutaneous Intervention in ST-Elevation Myocardial Infarction) trial showed no difference in 30-day mortality rates between radial and femoral access; however, the trial stopped early and therefore was underpowered to detect a mortality benefit.15 7.2 Use of Aspiration Thrombectomy Recommendation for Use of Aspiration Thrombectomy Referenced studies that support recommendation are summarized in the Evidence Table. COR LOE Recommendation 3: No benefit A 1. Among patients with STEMI undergoing PPCI, manual aspiration thrombectomy should not be performed routinely prior to PCI given lack of clinical benefit.*1–4 *Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”5 Synopsis Despite restoration of coronary patency, suboptimal myocardial perfusion resulting from distal embolization or microvascular obstruction is frequent and is associated with larger infarct size, impairment of LV function, and excess mortality rates.6,7 Removing coronary artery thrombus prior to balloon angioplasty, stent deployment, or both is an intuitive adjunct to PPCI that may yield putative clinical benefits. Routine manual thrombus aspiration performed via low profile catheters improved electrocardiographic and angiographic markers of myocardial perfusion in several clinical studies8,9 and reduced adverse events in a single-center trial.10,11 However, subsequent trials of manual aspiration thrombectomy have not demonstrated a clinical benefit.1,2,4,12,13 Similarly, results from a pooled analysis showed that mechanical thrombectomy during STEMI was not superior to conventional PCI alone. Recommendation-Specific Supportive Text 1 Results from several RCTs have shown that routine manual aspiration thrombectomy prior to PCI does not reduce MI size or improve clinical outcomes as compared with PCI alone.1,2,4,12,13 In a patientlevel, pooled analysis comprising 3 RCTs, aspiration thrombectomy did not reduce the primary endpoint of cardiovascular death at 30 days among patients with STEMI undergoing PPCI (n=18 306).3 Similarly, aspiration thrombectomy did not lower risks for recurrent MI, target vessel revascularization, stent thrombosis, or HF at 30 days or 1 year. With respect to safety, the incidence of stroke or transient ischemic attack at 30 days and 1 year was numerically higher, albeit not statistically significant, among patients who underwent aspiration thrombectomy. Reductions in cardiovascular death were lower while risks for stroke or transient ischemic attack were higher among those with a large thrombus burden treated with aspiration thrombectomy. Dedicated studies are warranted to evaluate the role of selective aspiration thrombectomy in those high-risk patients most likely to benefit from thrombus removal prior to PCI. Manual aspiration thrombectomy may be performed as a bailout procedure to remove thrombus that persists after balloon angioplasty or stent deployment, particularly with concomitant no-reflow. Estimates from RCT cohorts indicate that 4% to 7% of patients with STEMI undergoing PPCI will require bailout aspiration thrombectomy.1,2,10 7.3 Use of Intracoronary Imaging Recommendation for Use of Intracoronary Imaging Referenced studies that support recommendation are summarized in the Evidence Table. COR LOE Recommendation 1 A 1 In patients with ACS undergoing coronary stent implantation in left main artery or in complex lesions, intracoronary imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) is recommended for procedural guidance to reduce ischemic events.*1–11 *Adapted from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”12 Synopsis Intracoronary imaging serves as a valuable tool for guiding the placement of coronary stents, particularly in cases involving the left main artery or complex lesions, resulting in greater stent expansion, less stent malapposition, and fewer coronary dissections.1,2,4,13 IVUS provides a com- Downloaded from http://ahajournals.org by on October 7, 2026