Left main stenting: is it a different animal?

For several decades, coronary-artery bypass grafting (CABG) has been regarded as the treatment of choice for patients with unprotected left main coronary artery (LMCA) disease. However, because of marked advancements in techniques of percutaneous coronary intervention (PCI) with stenting and CABG, as well as adjunctive pharmacologic therapy, a new evaluation and review of current indications for optimal revascularisation therapy for LMCA disease may be required to determine the standard of care for these patients. The available current evidence suggests that the composite outcome of death, myocardial infarction and stroke is similar in patients with LMCA disease who are treated with PCI with stenting or CABG, the only difference was the rate of repeat revascularisation. Although PCI can be performed successfully in most LMCA lesions, "high-risk" anatomic subsets, especially involving distal LMCA bifurcation lesions, continue to present unique technical challenges to interventional cardiologists, and, therefore, an integrated approach combing advanced devices, tailored techniques, adjunctive support of physiologic and morphologic evaluation, and adjunctive pharmacologic agents should be reinforced to improve clinical outcomes.