The primary objective of therapeutic interventions in patients with acute ST-elevation myocardial infarction (STEMI) is to rapidly normalize tissue-level perfusion in order to prevent myocardial cell death. The preferred method for achieving this goal is by performing primary percutaneous coronary intervention (PCI). A major hurdle is the frequent dislodgement of particulate matter from the culprit lesion, which may embolize downstream and occlude the distal microvessels. Microvascular obstruction prevents myocardial reperfusion despite achievement of epicardial coronary artery patency and is associated with adverse clinical outcomes. A potential method for decreasing distal coronary embolization and microvascular obstruction is by aspiration thrombectomy, a technique designed to remove the particulate matter from the lesion prior to stent implantation. Initial studies of thrombectomy reported favorable outcomes in STEMI patients undergoing primary PCI, however subsequent large multicenter randomized trials failed to support these findings. This manuscript reviews the current data regarding aspiration thrombectomy in STEMI coronary interventions and discusses the role of this strategy in current practice.