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Published on: May 14, 2013
Patterns of Restenosis After Left Main Bifurcation Single- or Dual-Stenting: An EBC MAIN Trial Subanalysis
Annette Maznyczka1, Sandeep Arunothayaraj2, Adrian P Banning3
1Leeds Teaching Hospital NHS Trust, United Kingdom (A.M.).
Insights
Restenosis after left main (LM) bifurcation stenting most commonly occurs at the circumflex ostium, regardless of stent technique. Further strategies are needed to improve outcomes for this specific site.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- Left main (LM) bifurcation stenting is a complex procedure.
- Upfront dual-stenting has shown higher target lesion revascularization rates compared to stepwise provisional stenting at 3 years.
- The location and cause of restenosis after LM bifurcation stenting require further investigation.
Purpose of the Study:
- To investigate the location of restenosis after LM bifurcation stenting.
- To determine the impact of stent implantation technique (dual vs. single stenting) on restenosis patterns.
- To identify specific sites of restenosis within LM bifurcations.
Main Methods:
- Analysis of patients from the European Bifurcation Club Left Main Coronary Stent (EBC MAIN) trial who underwent target lesion revascularization.
- Assessment of restenosis location by a core laboratory.
- Definition of restenosis as ≥50% lesion diameter stenosis.
Main Results:
- The most frequent site of restenosis was the ostial circumflex artery (58%), irrespective of stent technique.
- The ostial circumflex was the culprit lesion in 71% of target lesion revascularization cases.
- Single stenting from LM to the circumflex artery was associated with worse stenosis in the left anterior descending artery ostium (49.8% vs. 19.8%).
Conclusions:
- The circumflex ostium is the most common site for revascularization after LM bifurcation stenting.
- Stent technique (dual vs. single) did not significantly impact stenosis at the circumflex ostium.
- Improved long-term strategies for percutaneous coronary intervention of the circumflex ostium are necessary.
Background:
In the randomized EBC MAIN trial (European Bifurcation Club Left Main Coronary Stent), target lesion revascularization at 3 years poststenting of left main (LM) bifurcations was more frequent with upfront dual-stenting compared with the stepwise provisional approach. Restenosis location and its relation to stent technique are poorly characterized. The aim of this study was to investigate restenosis location after LM bifurcation stenting, and the impact of stent implantation technique.
Methods:
Patients from the EBC MAIN trial who underwent target lesion revascularization during the 3-year follow-up had restenosis location assessed by the core laboratory. Restenosis was defined as ≥50% lesion diameter stenosis.
Results:
Among 48 patients with target lesion revascularization (mean age 70.3±10.6 years, 72.9% men), 31 were randomized to and treated with upfront dual-stenting, while 17 were randomized to the stepwise provisional technique, of whom 4 had dual-stent implantation. The treatment groups therefore comprised 35 dual-stented and 13 single-stented patients. The commonest pattern of subsequent restenosis was isolated ostial circumflex restenosis (58% of patients), regardless of dual- or single-stent implantation. The ostial circumflex was the culprit lesion for target lesion revascularization in 34 (71%) patients overall (dual- versus single-stented patients: 77% versus 54%; P=0.115). During the 3-year follow-up, the mean % diameter stenosis at the circumflex ostium was similar after dual- versus single-stent implantation (64.6% versus 60.5%, coefficient, -0.12 [95% CI, -0.46 to 0.22]; P=0.473). Single stenting from LM to the circumflex artery was associated with worse subsequent mean % diameter stenosis in the ostium of the left anterior descending artery versus single stenting from LM- left anterior descending (49.8% versus 19.8%, coefficient, 0.57 [95% CI, 0.003-1.13]; P=0.049).
Conclusions:
The circumflex ostium is the commonest site requiring revascularization after LM bifurcation stenting, irrespective of whether 1 or 2 stents were deployed. Strategies are needed to improve the long-term success of percutaneous coronary intervention to the circumflex artery ostium.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02497014.
