Ischemic injury at the tissue level related to distal embolization of thrombotic debris is described in at least 9–15% of patients undergoing primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI) . In one series, this was associated with an 8-fold increase in all-cause mortality at 5 years . Several medications (e.g., intracoronary nitroprusside, adenosine, nicardipine) as well as intracoronary devices (e.g., aspiration thrombectomy devices, distal embolic protection filters) have been used to reduce this risk but have failed to systematically be of proven benefit in reducing hard endpoints such as mortality. Direct stenting (DS) during PPCI in STEMI patients may potentially help reduce the risk of distal embolization and/or achieve thrombolysis in myocardial infarction (TIMI) 3 flow with increased myocardial blush grade. Population- and patient-level meta-analyses from randomized controlled trials have provided a signal that DS may lead to better ST-segment resolution and reduced rates of in-hospital cardiovascular mortality, albeit with no difference in recurrent myocardial infarction (MI) or target lesion revascularization . Similarly, data from a subgroup analysis of the HORIZONS-AMI trial demonstrated benefit in in-hospital mortality, which was sustained up to 1 year with DS compared with the conventional stenting (CS) approach . All these analyses were, however, limited by their small numbers and short duration of follow-up.