Acute coronary syndrome is associated with a high incidence of thrombus. The presence of coronary thrombus is often not appreciated on coronary angiography; however, simultaneous use of angioscopy or intravascular ultrasound increases the detection of thrombus. Forceful coronary injection, passage of intracoronary devices, balloon angioplasty and stenting in the presence of thrombus contribute to distal embolization by disrupting the thrombus. Clinically, intracoronary thrombus is associated with higher rates of death, myocardial infarction and target vessel revascularization. Removal of thrombus results in the improvement of markers of perfusion, which includes resolution of ST segment elevation, higher myocardial blush grade, and an increase in final thrombolysis in myocardial infarction flow as well as lower mortality. In this article, the authors discuss different mechanical thrombectomy devices and the literature available for their use in acute coronary syndrome.