Long-term outcomes in treating left main trifurcation coronary artery disease with the Paclitaxel-eluting stent
Nicolas W Shammas1, Eric J Dippel, Amber Avila
1Midwest Cardiovascular Research Foundation, Davenport, Iowa, USA.
Insights
Left main trifurcation stenting is complex and carries a high rate of adverse events, including stent thrombosis. This procedure may be best reserved for high-risk patients or those refusing bypass surgery.
Area of Science:
- Interventional Cardiology
- Cardiovascular Surgery
- Medical Device Technology
Background:
- Left main trifurcation stenting is a complex percutaneous coronary intervention (PCI) with limited reported experience.
- This study evaluates the safety and efficacy of using Taxus paclitaxel-eluting stents for left main trifurcation stenting.
Observation:
- The study included 20 consecutive patients undergoing left main trifurcation stenting.
- The primary endpoint was a composite of death, stent thrombosis, and target lesion revascularization (TLR).
- Follow-up was achieved in 85% of patients, with a median duration of 272 days.
Findings:
- The primary endpoint occurred in 29.4% of patients.
- Adverse events included sudden cardiac death (5.3%), acute stent thrombosis (10%), and TLR (11.8%).
- Stent thrombosis was noted in patients not receiving a clopidogrel load post-procedure or glycoprotein IIb/IIIa inhibitors, and in one case, without kissing balloon post-deployment.
Implications:
- Left main trifurcation stenting is associated with a high rate of adverse events and may be suitable for high-risk patients or those unsuitable for bypass surgery.
- Stent thrombosis is a significant concern, potentially linked to procedural factors like kissing balloon deployment and clopidogrel loading protocols.
- Further research with larger cohorts is needed to confirm these findings and optimize procedural techniques.
Background:
Left main trifurcation coronary artery disease stenting is a challenging and complex percutaneous procedure that has been infrequently reported. We present our own experience with left main trifurcation stenting using the Taxus paclitaxel-eluting stent (Boston Scientific).
Methods:
Twenty consecutive left main trifurcation stenting procedures were performed in 2005 at our institution. The primary endpoint of the study was the combined endpoints of death, acute stent thrombosis and target lesion revascularization (TLR). Conditional logistic regression analysis was performed to determine the predictors of the primary endpoint using a number of variable combinations.
Results:
The mean patient age was 71.7 +/- 8.9 years. The procedure was urgent in 10%, and the left main artery was unprotected in 95% of cases. Follow up was achieved in 17/20 (85%) patients, either from medical records or by phone calls. The follow-up median duration was 272 days (range 30 to 534 days). The primary endpoint was met in 5/17 (29.4%) patients. One of 19 patients (5.3%) had a sudden cardiac death 1 month after the procedure, 2/20 patients (10%) experienced an acute in-hospital stent thrombosis, and 2/17 (11.8%) patients underwent TLR. Conditional logistic regression analysis could not identify a relationship between the stenting method and the primary endpoint. The 2 patients who experienced in-hospital thrombosis were the only patients who received a clopidogrel load (600 mg) post-procedure after arrival to the floor, and were not on a glycoprotein IIb/IIIa inhibitor. All others received their clopidogrel either during the procedure (n = 7) or were on it chronically (n = 11). One patient with acute stent thrombosis did not have a kissing balloon performed post-stent deployment.
Conclusion:
Left main trifurcation stenting carries an overall high rate of adverse events and may need to be reserved for patients who are at high risk or who refuse bypass surgery. Overall TLR is low, but stent thrombosis remains a concern. Although we suspect that thrombosis could be related to failure to perform kissing balloon post-stent deployment and/or not receiving a clopidogrel load until after the procedure, the small number of patients in this study prevents us from making definite statistical conclusions about this observation.
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