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[Elective stenting of "unprotected" left main coronary stenosis in patients without contraindication to bypass
R Hofmann1, K Kerschner, M Grund
1I. Medizinische Abteilung mit Kardiologie, Allgemeines Krankenhaus Linz, Krankenhausstrasse 9, A-4020 Linz, Osterreich. robert.hofmann@akh.linz.at
Insights
Stenting unprotected left main coronary artery stenosis is a feasible alternative to surgery for select elderly patients. This study shows a 92% success rate with acceptable risks, offering a viable option when surgery is not optimal.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Unprotected left main coronary artery stenosis traditionally requires coronary artery bypass grafting.
- Percutaneous coronary intervention (PCI) is increasingly explored due to advancements in stenting and antiplatelet therapy.
- Patient selection is crucial, especially for those with high surgical risk.
Purpose of the Study:
- To evaluate the feasibility and safety of stenting unprotected left main coronary artery stenosis in patients unsuitable for bypass surgery.
- To assess the procedural success and early clinical outcomes of this interventional approach.
Main Methods:
- A retrospective analysis of 13 patients with unprotected left main coronary artery stenosis treated with stenting between 9/96 and 7/98.
- Patients were selected due to advanced age, co-morbidity, or diffuse coronary disease.
- Procedures involved balloon angioplasty followed by stent implantation, with surgical standby.
Main Results:
- Successful stent implantation was achieved in 12 out of 13 patients (92% success rate).
- One patient required emergency bypass surgery due to dissection during PCI.
- At a mean follow-up of 12 months, all patients were alive, with a 17% restenosis rate requiring re-intervention.
Conclusions:
- Stenting of unprotected left main coronary artery stenosis is technically feasible and can be considered in carefully selected patients.
- This approach offers an acceptable risk profile as an alternative to coronary artery surgery in high-risk individuals.
- Further research is warranted to optimize patient selection and long-term outcomes.
Abstract:
Coronary surgery is at this point of time the standard therapy of unprotected left main coronary artery stenosis. Coronary angioplasty (PTCA) is performed only in bail out situations. The number of publications of successful percutaneous intervention in unprotected left main coronary stenosis is increasing because of increasing use of stents and ticlopidine to avoid stent-thrombosis. From 9/96 to 7/98, 13 patients with unprotected left main coronary stenosis were treated with stents. All of them were accepted by the heart surgeon for bypass surgery but were not considered to be optimal candidates due to advanced age of more than 80 years (n = 5), significant co-morbidity (n = 2) or diffuse diseased peripheral coronary segments (n = 6). Mean age of patients was 74 +/- 10 years, 9 were male, and all patients presented with angina III-IV (CCS). Mean ejection fraction was 55 +/- 15%. Localization of stenoses were classified as ostial (n = 5), middle (n = 3), and bifurcational (n = 6). One patient had stenoses both in the ostium and in the bifurcation. In all cases a PTCA of the culprit stenosis was performed prior to stent implantation. The mean diameter of the stents used was 3.3 +/- 0.3 mm and the mean length was 11 +/- 4 mm. In 6 patients a PTCA of either left anterior descendens (LAD) or right coronary artery was performed in the same session. In 4 of these patients it was followed by a stent implantation. All procedures were performed with surgical stand-by, an intraaortal balloon pump was available, but was not uses prophylactically. Stent implantation could be performed successfully in 12 out of the 13 patients (success rate 92%). In bifurcational stenoses stents were positioned with the proximal end in the left main and the distal end in the LAD. Significant injury or occlusion of the circumflex artery was not observed. In one patient with bifurcational stenosis with severe calcification it was not possible to cross the lesion with an accurate sized balloon. Trying to cross with a smaller balloon (2.5 mm) resulted in dissection of the left main coronary artery which could not be reopened again by catheter technique. This patient was transferred to the operating room under conditions of cardiopulmonary resuscitation and a bypass surgery was performed. He was dismissed from the hospital with no evidence of perioperative myocardial infarction. The mean time for follow-up was 12 +/- 7 months, all patients are still alive. In 6 patients an angiography was performed during follow-up because of suspicion of recurrent ischemia. Two patients out of these 6 had restenoses in the left main coronary artery which were re-dilated (17%). Another 2 patients had stenoses in other coronary segments and were also dilated. Thus, stenting of left main coronary artery stenoses is feasible, however, with acceptable risks and could be considered in selected patients as an alternative to coronary artery surgery.