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Published on: May 14, 2013
Left Main Stenting in Comparison With Surgical Revascularization: 10-Year Outcomes of the (Left Main Coronary Artery
Pawel E Buszman1, Piotr P Buszman2, Iwona Banasiewicz-Szkróbka3
1American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland; Medical University of Silesia, Katowice, Poland.
Insights
Left main stenting shows a numerically favorable, though not statistically significant, 10-year outcome compared to coronary artery bypass grafting for low-to-medium complexity disease. This suggests stenting is a viable alternative to surgery for these patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- The long-term outcomes of left main stenting versus surgical revascularization are not well-established.
- Unprotected left main coronary artery stenosis requires careful treatment consideration.
Purpose of the Study:
- To report the 10-year clinical follow-up of the LE MANS trial, comparing percutaneous coronary intervention (PCI) with stenting to coronary artery bypass grafting (CABG).
Main Methods:
- A prospective, multicenter randomized trial assigned 105 patients with low/medium complexity left main stenosis to PCI (n=52) or CABG (n=53).
- Drug-eluting stents were used in 35% of PCI cases; 81% of CABG cases utilized arterial grafts.
- Follow-up included all-cause mortality and major adverse cardiovascular and cerebral events (MACCE) up to 9.8 years.
Main Results:
- At 10 years, ejection fraction trended higher with stenting (54.9% vs. 49.8%).
- Mortality (21.6% vs. 30.2%) and MACCE (51.1% vs. 64.4%) were not significantly different, numerically favoring stenting.
- Rates of myocardial infarction, stroke, and repeat revascularization were comparable between PCI and CABG.
Conclusions:
- Percutaneous coronary intervention with stenting offers a numerically favorable, though statistically non-significant, long-term safety and efficacy profile compared to CABG for unprotected left main stenosis.
- Stenting represents a viable alternative therapeutic option to CABG in selected patients with low-to-medium complexity coronary artery disease.
Objectives:
This study has reported 10-year clinical follow-up of patients enrolled in the prospective, randomized LE MANS (Left Main Stenting) trial.
Background:
The very long-term outcome after left main stenting in comparison with surgical revascularization remains unknown.
Methods:
In this prospective, multicenter trial, we randomly assigned 105 patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease according to SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score to percutaneous coronary intervention (PCI) with stenting (n = 52) or coronary artery bypass grafting (CABG) (n = 53). Drug-eluting stents were implanted in 35%, whereas arterial grafts to the left anterior descending artery were utilized in 81%. Currently, the mean long-term follow-up was collected at 9.8 ± 1.0 years. Follow up for all-cause mortality is complete, whereas the incidence of major adverse cardiovascular and cerebral events (MACCE) was reported from 90% of patients. Ambulatory follow-up was completed in 46 (43.9%) patients.
Results:
At 10 years, there was a trend toward higher ejection fraction in stenting when compared with surgery (54.9 ± 8.3% vs. 49.8 ± 10.3%; p = 0.07). The mortality (21.6% vs. 30.2%; p = 0.41) and MACCE (51.1% vs. 64.4%; p = 0.28) were statistically not different between groups; however, numerically the difference was in favor of stenting. Similarly, there was no difference in the occurrence of myocardial infarction (8.7 vs. 10.4%; p = 0.62), stroke (4.3 vs. 6.3%; p = 0.68), and repeated revascularization rates (26.1% vs. 31.3%; p = 0.64). The probability of very long-term survival up to 14 years was comparable between PCI and CABG (74.2% vs. 67.5%; p = 0.34; hazard ratio: 1.45, 95% confidence interval: 0.67 to 3.13); however, there was a trend toward higher MACCE-free survival in the PCI group (34.7% vs. 22.1%; p = 0.06; hazard ratio: 1.71, 95% confidence interval: 0.97 to 2.99).
Conclusions:
In patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease, stenting offers numerically, but statistically nonsignificant, favorable long-term outcome up to 10 years in terms of safety and efficacy outcome measures, therefore, constitutes an alternative therapy for CABG.
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