Revascularization for unprotected left main disease: evolution of the evidence basis to redefine treatment standards

Determining the most appropriate revascularization strategy for patients presenting with unprotected left main coronary (UPLM) disease has been a topic of great recent interest. During this current decade, there have been multiple clinical trials and registries addressing this subject. Previously, UPLM disease has almost exclusively resulted in utilizing a surgical revascularization treatment strategy. However, recent improvements in percutaneous coronary intervention (PCI) techniques in parallel with the benefits of drug-eluting stents (DES) to reduce clinical restenosis have enabled further investigation in catheterization-based treatment strategies as possible alternative therapeutic options. These advances as well as an increased understanding of both the procedural and anatomical challenges involved with complex coronary interventions have allowed further advancements in the field. Better adjunctive antithrombotic pharmacological therapy in the PCI setting has favored such progress. American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions guidelines do not currently endorse the performance of PCI as an appropriate alternative to surgical revascularization for patients with UPLM disease. This paper is a review of the current evidence on UPLM PCI and proposes future directions in this evolving field.