Management of thrombus in coronary lesions remains a challenge that is frequently encountered during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) and is usually associated with poor clinical outcomes. At the same time, the optimum management of such lesions remains a dilemma. Multiple thrombus removal procedures have emerged with the short-term aim of improving myocardial perfusion and a longer-term aim of decreasing the incidence of both major adverse cardiac events (MACE) and all-cause mortality. In this review, we will highlight the main procedures utilized for thrombus removal during primary PCI for STEMI, with particular emphasis on aspiration thrombectomy. We will also approach possible theories that might explain the apparent lack of clinical benefit recently shown with such procedures.