Recommendation 2015 Focused Update Recommendations Comments Class IIa Class IIb Manual aspiration thrombectomy is reasonable for patients undergoing (Level of Evidence: B) The usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established.33 37 (Level of Evidence: C-LD) Modified recommendation (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI). Class III: No Benefit Routine aspiration thrombectomy before primary PCI is not (Level of Evidence: A) New recommenda- tion ( Class III: No Benefit added for routine aspiration thrombectomy before PCI). PCI indicates percutaneous coronary intervention; and LD, limited data. the aspiration thrombectomy group. An updated meta-analysis that included these 3 trials among a total of 17 trials (n=20960) found no significant reduction in death, reinfarction, or stent thrombosis with routine aspiration thrombectomy. Aspiration thrombectomy was associated with a small but nonsignificant increase in the risk of stroke.33 Several previous studies have found that higher thrombus burden in patients with STEMI is independently associated with higher risks of distal embolization, no-reflow phenom- enon, transmural myocardial necrosis, major adverse cardiac events, stent thrombosis, and death.38 42 However, subgroup analyses from the TASTE and TOTAL trials did not suggest rel- ative benefit from aspiration thrombectomy before primary PCI in patients with higher thrombus burden or in patients with ini- tial Thrombolysis in Myocardial Infarction (TIMI) flow grade 0 1 or left anterior descending artery/anterior infarction.34,35 On the basis of the results of these studies, the prior Class IIa recommendation for aspiration thrombectomy has been changed. Routine aspiration thrombectomy before primary PCI is now not recommended (Class III: No Benefit, LOE A). There are insufficient data to assess the potential benefit of a strategy of selective or bailout aspiration thrombectomy (Class IIb, LOE C-LD). 