Ostial and midshaft lesions vs. bifurcation lesions in 1111 patients with unprotected left main coronary artery stenosis treated with drug-eluting stents: results of the survey from the Italian Society of Invasive Cardiology

Palmerini, Tullio; Sangiorgi, Diego; Marzocchi, Antonío; Tamburino, Corrado; Sheiban, Imad; Margheri, Massimo; Vecchi, Giuseppe; Sangiorgi, Giuseppe; Ruffini, M.; Bartorelli, Antonio L.; Briguori, Carlo; Vignali, Luigi; Pede, Francesco Di; Ramondo, Angelo; Inglese, Luigi; Bolognese, Leonardo; Benassi, Alberto; Palmieri, Cataldo; Filippone, Vincenzo; Barlocco, Fabio; Lauria, Giulia; Servi, Stefano De

doi:10.1093/eurheartj/ehp223

Cited by 114 publications

(71 citation statements)

References 16 publications

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“…Although, there is an ongoing debate [53] , a recent report proposed that the complex stenting technique might be associated with the high occurrence of restenosis compared with the simple stenting technique [8] . A subgroup analysis of a large Italian study supported this hypothesis that a single stenting strategy for bifurcation LMCA lesions had a comparable long-term outcome to that for non-bifurcation lesions [24] . Taken together, these finding suggest that the simple stenting approach (LMCA to left anterior descending artery with optional treatment in the circumflex artery) is primarily recommended in patients with a relatively patent or diminutive circumflex artery.…”

Section: Recurrent Revascularizationmentioning

confidence: 81%

Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis

Park¹,

Kim²

2012

Textbook of Interventional Cardiology

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Hemodynamically significant left main coronary artery stenosis (LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left circumflex artery has no previous patent grafts. Previous randomized studies have demonstrated a significant reduction in mortality when revascularization by coronary artery bypass graft (CABG) surgery was undertaken compared with medical treatment. Therefore, current practice guidelines do not recommend percutaneous coronary intervention (PCI) for such a lesion because of the proven benefit of surgery and high rates of restenosis with the use of bare metal stents. However, with the advent of drug-eluting stents (DES), the long term outcomes of PCI with DES to treat unprotected LMCA stenoses have been acceptable. Therefore, apart from the current guidelines, PCI for treatment of unprotected LMCA stenosis is often undertaken in individuals who are at a very high risk of CABG or refuse to undergo a sternotomy. Future randomized studies comparing CABG vs PCI using DES for treatment of unprotected LMCA stenosis would be a great advance in clinical knowledge for the adoption of appropriate treatment.

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Section: Recurrent Revascularizationmentioning

confidence: 81%

Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis

Park¹,

Kim²

2012

Textbook of Interventional Cardiology

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“…12 Compared with ostial or midshaft lesions, the distal LM bifurcation was associated with a 50% excess risk of adverse outcomes, which was mainly driven by bifurcation lesions that were treated with complex stenting, as no difference in outcomes was observed between patients with 1-stent bifurcation treatment and those with ostial or midshaft LMCA lesions.…”

Section: Distal Bifurcation Diseasementioning

confidence: 90%

Left Main Stenting - Now and Future -

Park

2011

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp he standard revascularization choice for unprotected left main coronary artery (LMCA) disease is coronary-artery bypass grafting (CABG), based on the documented efficacy and survival advantage of CABG in reference to medical therapy since the 1970s. 1,2 However, because of the anatomically easy accessibility and relatively large caliber of the LMCA, percutaneous coronary intervention (PCI) for LMCA disease has been attractive to the interventional cardiologist. Technical advances in both PCI and stent technology have emboldened the physician to test the feasibility of LMCA intervention and, coupled with the widespread availability of drug-eluting stents (DES), has led to a reevaluation of the role of PCI as a viable alternative treatment for unprotected LMCA disease. 3 However, there are limited data regarding the long-term outcomes of PCI and limited numbers of well-conducted, large randomized trials comparing PCI and CABG for such patients. We therefore reviewed the current evidence and future prospects of PCI with stenting of the LMCA and the alternative role of PCI in reference to standard CABG for patients with LMCA disease. Outcomes of PCI With StentingOver the past years, using PCI with bare metal stents (BMS), LMCA intervention has shown its feasibility and acceptable short-and mid-term outcomes. Due to marked improvement in the efficacy of DES compared to BMS, many experienced interventional cardiologists currently perform PCI with DES for patients with unprotected LMCA disease. Several observational studies, although limited by their non-randomized nature, small number of patients, and short follow-up periods, have shown promising outcomes for PCI using DES compared with BMS. 4-7 However, there remains some clinical uncertainty regarding the optimal stent type for use in unprotected LMCA disease. The use of DES in left main (LM) disease has been regarded as an off-label application and adverse events associated with DES has been pronounced, in particular late stent thrombosis. Recently, a well-conducted, large meta-analysis comparing outcomes for DES and BMS afterPCI for unprotected LMCA disease was reported. 8 A total of 44 studies and 10,342 patients who received a DES or BMS were analyzed. The respective (DES vs. BMS) cumulative event rates at 3 years were 8.8% and 12.7% for death, 4.0% and 3.4% for MI, 8.0% and 16.4% for target vessel revascularization/target lesion revascularization (TVR/TLR), and 21.4% and 31.6% for major adverse cardiovascular events (MACE). Adjusted outcomes at 3 years favored DES (Figure). Ostial and/or Shaft DiseaseThe feasibility and success of PCI with stent implantation for LMCA disease require careful evaluation of the lesion's com- For several decades, based on clinical trials comparing coronary-artery bypass grafting (CABG) with medical therapy, bypass surgery has been regarded as the treatment of choice for patients with unprotected left main coronary artery (LMCA) disease...

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“…29 In the subgroup of patients with ULM disease, MACCE was similar for patients with Figure 1). Observational data has demonstrated worse outcomes for patients undergoing PCI for distal ULM disease, 34,35 and patients with higher SYNTAX scores are more likely to have distal bifurcation involvement.…”

Section: Selective Use Of Percutaneous Coronary Intervention -Anatomimentioning

confidence: 99%

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Unprotected Left Main Disease – A Review

McNulty

2013

Interventional Cardiology Review

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The debate over the optimal mode of revascularisation for unprotected left main (ULM) coronary artery disease intensified with the advent of drug-eluting stents (DES). Professional society guidelines addressing ULM disease have been revised at an increasing frequency, 1,2 the significance of randomised comparisons has been variously interpreted, and observational comparisons have become a veritable cottage industry. Making matters even more complicated, the debate is often depicted in simplified, polarised terms in the lay press and at national meetings. Not surprisingly, patients and clinicians alike are often left confused. The intention of this review is to place the 'debate' in context and highlight a few of the crucial issues in generalising the evidence base for those who manage ULM disease in clinical practice. The Evolution of the 'Gold Standard'Coronary artery bypass graft (CABG) surgery had been unchallenged as the standard of care for patients with ULM disease for decades. Before addressing the evidence for percutaneous coronary intervention (PCI) as an alternative, it is important to briefly consider the quality of that supporting CABG as an alternative to medical therapy for ULM disease. Only two of the seminal randomised trials comparing CABG with medical therapy included patients with left main disease. Observational data gave support to this finding, 6 and the paradigm of CABG to prolong longevity for left main disease remained essentially unchallenged for three decades.There are important caveats concerning these early randomised trials that warrant emphasis. First, only 150 patients in total were randomised, quite a small number by contemporary standards.Second, they represent a pooled subgroup analysis and should be viewed with the attendant limitations of such analyses.7 Third, and perhaps most importantly, both surgery and medical therapy have evolved tremendously over the ensuing decades. CABG now routinely includes the use of mammary conduits, and surgical mortality has improved considerably -in the registry component of the CoronaryArtery Surgery Study (CASS) it was over 4 % for patients with left main disease, a rate that most would consider unacceptable today.Conversely, 'medical therapy' at the time of these trials consisted of digitalis, beta-blockers and nitrates. Not even aspirin was routinely administered. Suffice it to say, the evidence base for the longevity benefits of CABG over medical therapy for treating left main coronary disease is neither large nor current. Observational Trials of Coronary Artery Bypass Graft for Unprotected Left Main DiseaseAlthough randomised clinical trials (RCTs) are considered the most robust assessment of efficacy, they have important limitations. Patients in RCTs tend to be younger, more often male and have fewer co-morbid conditions. 8 Generalising results from these trials must therefore be done with caution. For example, the vast majority of patients in the aforementioned Veterans Affairs and European studies were under 60 years of age and most...

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Ostial and midshaft lesions vs. bifurcation lesions in 1111 patients with unprotected left main coronary artery stenosis treated with drug-eluting stents: results of the survey from the Italian Society of Invasive Cardiology

Abstract: Patients with bifurcations have a worse outcome than patients with ostial and midshaft lesions. However, the technique used to treat bifurcations has a significant impact on clinical outcomes.

Cited by 114 publications

References 16 publications

Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis

Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis

Left Main Stenting - Now and Future -

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Unprotected Left Main Disease – A Review

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