Optimal minimal stent area after crossover stenting in patients with unprotected left main coronary artery disease
Ju Hyeon Kim1, Do-Yoon Kang1, Jung-Min Ahn1
1Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Insights
Optimal stent expansion in the left main coronary artery (LM) is crucial for preventing major adverse cardiac events (MACE). This study defines minimal stent area (MSA) thresholds using intravascular ultrasound (IVUS) to guide LM percutaneous coronary intervention (PCI).
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging
Background:
- Intracoronary imaging improves percutaneous coronary intervention (PCI) outcomes for left main coronary artery (LM) disease compared to angiography alone.
- Optimal minimal stent area (MSA) thresholds for predicting cardiovascular outcomes after LM PCI remain undefined.
Purpose of the Study:
- To evaluate intravascular ultrasound (IVUS)-measured segmental MSA after LM crossover stenting.
- To establish optimal MSA thresholds for predicting 5-year major adverse cardiac events (MACE).
Main Methods:
- Retrospective analysis of 829 patients undergoing IVUS-guided PCI for unprotected LM disease using a single-stent crossover technique.
- Final MSA measurement at proximal LM, distal LM, and left anterior descending artery (LAD) ostium.
- Primary outcome: 5-year MACE (all-cause death, myocardial infarction, target lesion revascularisation).
Main Results:
- Identified MSA cutoffs for predicting 5-year MACE: proximal LM 11.4 mm², distal LM 8.4 mm², LAD ostium 8.1 mm².
- Proximal LM stent underexpansion significantly increased MACE risk (adjusted HR 2.34).
- Simultaneous distal LM and LAD ostium underexpansion markedly elevated MACE risk (adjusted HR 2.57).
Conclusions:
- Sufficient stent expansion in the proximal LM and avoiding underexpansion in the distal LM and LAD ostium are vital for favorable long-term outcomes.
- The identified MSA thresholds provide practical benchmarks for optimizing stent placement during LM PCI.
Background:
Intracoronary imaging-guided percutaneous coronary intervention (PCI) has demonstrated clinical benefit over angiography-guided PCI for left main coronary artery (LM) disease. However, the optimal minimal stent area (MSA) thresholds to predict cardiovascular outcomes remain incompletely defined.
Aims:
This study aimed to evaluate intravascular ultrasound (IVUS)-measured segmental MSA after LM crossover stenting.
Methods:
We identified 829 consecutive patients who underwent IVUS-guided PCI for unprotected LM disease using a single-stent crossover technique. The final MSA was measured at the proximal LM, distal LM, and left anterior descending artery (LAD) ostium. The primary outcome was 5-year major adverse cardiac events (MACE), including all-cause death, myocardial infarction, and target lesion revascularisation.
Results:
The MSA cutoff values best predicting 5-year MACE were 11.4 mm² for the proximal LM (area under the curve [AUC] 0.62), 8.4 mm² for the distal LM (AUC 0.58), and 8.1 mm² for the LAD ostium (AUC 0.57). Based on these cutoff values, stent underexpansion in the proximal LM was significantly associated with increased risk of 5-year MACE (adjusted hazard ratio [HR] 2.34; p<0.001). Additionally, patients with simultaneous stent underexpansion in both the distal LM and LAD ostium exhibited a significantly higher risk of 5-year MACE compared with those having adequate expansion or only single-site underexpansion (adjusted HR 2.57; p<0.001).
Conclusions:
Achieving sufficient stent expansion in the proximal LM and preventing underexpansion in both the distal LM and LAD ostium are critical for improving long-term clinical outcomes. The identified MSA thresholds may serve as practical benchmarks for stent optimisation during LM PCI.
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