Percutaneous coronary intervention in unprotected left main disease: a status report
L I Kupferwasser1, M S Lee, J N Schapira
1Division of Cardiology, Cedars-Sinai Medical Center, University of California-Los Angeles School of Medicine, 8631 W. Third Street, Los Angeles, CA 90048, USA.
Insights
Drug-eluting stents show promise for percutaneous coronary intervention (PCI) in unprotected left main (LM) artery cases. However, complex bifurcation lesions still pose challenges, requiring more research before LM-PCI replaces coronary artery bypass grafting (CABG).
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Percutaneous coronary intervention (PCI) of the unprotected left main (LM) artery is generally not recommended due to historical poor outcomes.
- Coronary artery bypass grafting (CABG) remains the gold standard for LM revascularization.
- Recent advancements in drug-eluting stents (DES) have spurred renewed interest in LM-PCI.
Purpose of the Study:
- To evaluate the current role and outcomes of DES-based LM-PCI.
- To compare outcomes for ostial/mid-shaft LM lesions versus complex bifurcation lesions.
- To identify areas needing further research for routine LM-PCI adoption.
Main Methods:
- Review of single-center, non-randomized registries evaluating DES for LM-PCI.
- Analysis of outcomes based on lesion location (ostial/mid-shaft vs. bifurcation).
- Assessment of target vessel failure rates and mortality.
Main Results:
- DES-PCI shows potential for ostial or mid-shaft LM lesions with low mortality and target vessel failure.
- Complex bifurcation LM lesions treated with PCI have higher target vessel failure rates (2-38%), especially with dual stenting.
- Single crossover stenting may be suitable when the circumflex ostium is not involved in bifurcation lesions.
Conclusions:
- DES-PCI is a viable option for select unprotected LM lesions, particularly ostial/mid-shaft.
- Complex bifurcation LM PCI outcomes require further investigation and optimization.
- More randomized trials and registry data are essential to establish LM-PCI as a routine alternative to CABG.
Abstract:
Percutaneous coronary intervention (PCI) of the unprotected left main (LM) artery is currently not recommended as a routine procedure based on the history of inferior outcomes of LM percutaneous transluminal coronary angioplasty and bare metal stenting. Instead, surgical revascularization (coronary artery bypass grafting, CABG) is considered to be the gold standard. There is renewed interest in LM-PCI because of improved outcomes of PCI utilizing drug eluting stents (DES) in multiple randomized trials. Several single-center non-randomized registries have evaluated the role of DES for LM-PCI. Data suggest a low mortality and target vessel failure of ostial LM or mid-shaft lesions in contrast to bifurcation lesions, which frequently require complex dual stenting techniques. The complex PCI in the bifurcation is associated with the increased occurrence of target vessel failure ranging from 2% and 38%. The rate of target vessel failure in bifurcation lesions is less in patients in whom the circumflex ostium is not involved so that single cross over stent is suitable. Current recommendations call for a follow-up angiography at 4-6 months to detect LM restenosis prior to a potentially fatal clinical event. The question of the duration of dual antiplatelet therapy in patients who underwent LM-PCI is unanswered. More registry data and randomized trials are needed before unprotected LM-PCI can be routinely offered to patients as an alternative to CABG.
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