Retrograde left main stenting

Percutaneous transluminal coronary angioplasty of protected left main coronary artery stenosis is usually performed by an antegrade approach. In this case report, we describe left main coronary artery stenting by a retrograde approach through a saphenous venous graft in a patient in whom the antegrade approach was considered less appropriate due to chronic ostial occlusion. © 1996 Wiley-Liss, Inc.     

Ten-year outcomes of early generation sirolimus- versus paclitaxel-eluting stents in patients with left main coronary artery disease

To compare 10-year outcomes after implantation of sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES) for left main coronary artery (LMCA) stenosis. Very long-term outcome data of patients with LMCA disease treated with drug-eluting stents (DES) have not been well described. In 10-year extended follow-up of the MAINCOMPARE registry, we evaluated 778 patients with unprotected LMCA stenosis who were treated with SES (n = 607) or PES (n = 171) between January 2000 and June 2006. The primary composite outcome (a composite of death, myocardial infarction [MI] or target-vessel revascularization [TVR]) was compared with an inverse-probability-of-treatment-weighting (IPTW) adjustment. Clinical events have linearly accumulated over 10 years. At 10 years, there were no significant differences between SES and PES in the observed rates of the primary composite outcome (42.0% vs. 47.4%; hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.66–1.10), and definite stent thrombosis (ST) (1.9% vs. 1.8%; HR 1.02, 95% CI 0.28–3.64). In the IPTW-adjusted analyses, there were no significant differences between SES and PES in the risks for the primary composite outcome (HR 0.89, 95% CI 0.65–1.14) or definite ST (adjusted HR 1.05, 95% CI 0.29–3.90). In patients who underwent DES implantation, high overall adverse clinical event rates (with a linearly increasing event rate over time) were observed during extended follow-up. At 10 years, there were no measurable differences in outcomes between patients treated with SES vs. PES for LMCA disease. The incidence of stent thrombosis was quite low and comparable between the groups.     

Potential risk of provisional stenting in left main coronary artery bifurcation in multivessel‐related acute coronary syndrome

We present a case of an elderly man suffering from an acute coronary syndrome (ACS) with preshock vital signs and remarkable ST–T wave depression in leads V4–V6, and ST elevation in lead aVR. Coronary angiography showed total occlusion of the right coronary artery (RCA) and impending occlusion in the distal left main coronary artery (LMCA) with a tandem lesion in the proximal left anterior descending artery (LAD). After insertion of an intra‐aortic balloon pump both the LAD and left circumflex artery (LCX) were dilated alternatively; and cross‐over stenting in the LMCA bifurcation was subsequently performed. However, total occlusion of the LCX occurred and it caused acute hemodynamic collapse and ventricular fibrillation storm. Immediate installation of percutaneous cardio‐pulmonary support system allowed stent deployment to be performed in the RCA and subsequent reopening of the LCX that led to a return to sinus rhythm. The patient recovered almost normal left ventricular wall motion and previous activity without any neurological deficit within 2 weeks. Provisional stenting in ACS in the LMCA bifurcation with multivessel disease has a potential risk of acute hemodynamic collapse; a planned two‐stent deployment strategy may assure a higher rate of safety in such cases. © 2011 Wiley‐Liss, Inc.     

Bail-out stenting for left main coronary artery dissection during catheter-based procedure: acute and long-term results

BACKGROUND: The optimal treatment of patients with left main coronary artery (LMCA) dissection during catheter-based procedure remains uncertain. HYPOTHESIS: In cases with significant LMCA dissection occurring during catheter-based procedure, prompt stent implantation may be safe and associated with favorable clinical outcome. METHODS: We evaluated the acute and long-term results of bail-out stenting for LMCA dissection occurring during a catheter-based procedure in 10 patients. RESULTS: Initially, there was no significant stenosis of LMCA segments in these patients. Catheter-induced dissection occurred in eight patients (during diagnostic angiography in three patients and during guiding catheter manipulation in five patients). Two patients suffered dissection in the setting of stent deployment in other vessels. Therefore, bail-out stenting for LMCA dissection was performed in a total of 10 patients. In four patients, hypotension developed and an intra-aortic balloon pump was placed during the procedure. Stents were successfully deployed in all patients; there was no in-hospital mortality. Six-month angiographic follow-up was performed in eight patients. No angiographic restenosis (diameter stenosis > or = 50%) was observed in any patient at follow-up study. During a mean follow-up of 31 +/- 25 months after hospital discharge, there was no major adverse cardiac event (death, myocardial infarction, and target lesion revascularization). CONCLUSIONS: Bail-out LMCA stenting is technically feasible and showed good acute and long-term results in a small series of patients.     

Primary percutaneous coronary intervention of an unprotected left main using mini‐crush drug‐eluting stents facilitated by intracoronary reteplase

Patients suffering from acute myocardial infarction with involvement of unprotected left main (LM) coronary artery disease represent a very high‐risk subgroup. A 37‐year‐old male patient was admitted with posterolateral acute myocardial infarction and in borderline hemodynamic condition. His left ventricular ejection fraction was 30% with posterior, lateral wall, and apical akinesis along with mild mitral regurgitation. Emergency coronary angiography demonstrated ostial occlusion of the left circumflex artery (without stump, flow Thrombolysis in Myocardial Infarction 0/Rentrop 0) and severe distal LM disease with superimposed thrombus. The primary percutaneous coronary intervention procedure combined intracoronary reteplase plus thrombus aspiration to restore flow in the left circumflex and deployment of two everolimus‐eluting stents with mini‐crush technique to successfully reconstruct the LM bifurcation. The patient recovered without complications and had a favorable outcome at mid‐term.© 2011 Wiley‐Liss, Inc.     

Immediate and long-term outcome after angioplasty with stenting of the left main coronary artery

INTRODUCTION AND OBJECTIVES: Coronary artery bypass graft surgery is the treatment of choice for severe left main coronary artery stenosis. The results of a number of multicenter trials have suggested angioplasty with stenting as a possible alternative treatment. The aim of the present study was to analyze the immediate and long-term results of angioplasty with stenting of the left main coronary artery, and to identify factors predictive of death. PATIENTS AND METHOD: A total of 38 nonconsecutive patients (mean age 69 [8] years) with a severe lesion in the left main coronary artery were treated with angioplasty and stenting between November 1997 and March 2003. The procedure was elective in 27 patients and urgent in the remaining 11. In 23 patients (60.5%) the left main coronary artery was not protected by aortocoronary bypass. All patients underwent clinical follow-up examination at 25 (20) months. RESULTS: Angiographically documented success was obtained in all patients. However, one patient died from acute occlusion one hour after the operation. Four patients (10%) had a non-Q-wave myocardial infarction. In-hospital mortality was 15.8% (6/38 patients). Five of the 11 patients (45.4%) who underwent emergency angioplasty and stenting died in the hospital from acute myocardial infarction complicated by severe (Killip grade III-IV) heart failure. However, only one of 27 patients (3.7%) in the elective surgery group died (P=.007). Major clinical cardiac events during follow-up occurred in 5 patients (13%); 3 died and the other 2 had recurrent angina. All patients who died had an unprotected left main coronary artery. Cumulative survival rates for the elective group were 92 (0.5)% at 6 months, 88 (0.6)% at 1 year and 86 (0.7)% at 3 years, respectively. For the emergency surgery group cumulative survival rate was 54 (0.2)% at 6 months (P<.05). CONCLUSIONS: Elective angioplasty and stenting of the left main coronary artery in selected patients was associated with a high immediate success rate. In patients who underwent elective angioplasty and stenting, the incidence of major cardiac events during follow-up was relatively low. Emergency angioplasty and signs of left ventricular dysfunction were the main predictors of in-hospital mortality.     

Stenting of a left main coronary artery compressed by a dilated main pulmonary artery

Left main coronary artery (LMCA) disease caused by external compression by a dilated main pulmonary artery (MPA) is an uncommon clinical entity but is one of the reversible causes of chest pain in patients with pulmonary hypertension. Traditionally, treatment of LMCA disease involves coronary artery bypass graft surgery. However, for LMCA compression by a dilated MPA, coronary angioplasty with stenting has recently been reported to have good outcomes and might be more suitable in some patients with high risk associated with surgery. Herein, we describe a 54‐year‐old man with pulmonary arterial hypertension and external compression of the LMCA by the dilated main pulmonary artery that was treated with angiographic and intravascular ultrasound‐guided coronary angioplasty and stenting. Also we briefly review current literatures about LMCA compression by a dilated MPA. © 2013 Wiley Periodicals, Inc.     

Catastrophic left main coronary artery occlusion following diagnostic coronary angiography: Salvage by emergency left main coronary artery stenting

Acute occlusion of left main coronary artery after diagnostic angiography can be rapidly fatal. We describe two patients with left main disease that developed cardiac arrest shortly after diagnostic coronary angiography. They were both successfully treated with emergency left main stenting while cardiopulmonary resuscitation was being performed. Patients with left main disease should be carefully monitored after diagnostic angiography to allow prompt recognition of acute occlusion. Emergency stenting may be required for salvaging the patients.     

Treatment of unprotected left main stenoses with Palmaz-Schatz stenting

Coronary artery bypass surgery remains the standard modality for revascularization of significant left main coronary artery stenoses. Despite major improvement in equipment and operator technique, balloon angioplasty of significant unprotected left main obstruction generally is contraindicated. When catheter intervention is required, Palmaz-Schatz stenting may offer better predictability of the acute result, and possibly improved long-term outcome. © 1996 Wiley-Liss, Inc.     

直接支架术治疗左冠状动脉主干病变(附三例报告)

目的评估直接支架术治疗左冠状动脉主干病变的可行性及其术后即刻与远期疗效。方法选择性对３例左主干病变患者进行不预扩左主干的支架直接置入术,其中２例置入ＭｕｌｔｉＬｉｎｋ支架,一例置入ＢｅＳｔｅｎｔ支架。每例均采用高压（１６至２２个大气压）扩张１至２次,持续时间１０至２０秒。结果３例左主干病变直接支架置入术均获成功,术中未发生并发症,术后临床随访６、７及１２个月均无心绞痛症状复发。结论选择性左主干病变直接置入支架术安全、有效、可行。该方法对左主干病变治疗较其他部位及方法可能更为有利,但此需得到大组病例及随机对比试验证实。     

Complete occlusion of the left main coronary artery: clinical and angiographic observations in five cases

Involvement of the left main coronary artery is observed in approximately 5 to 8% of patients with coronary artery lesions detected by coronary angiography, but occlusion of the left main artery is a very infrequent finding. Out of approximately 4000 patients undergoing coronary angiography, four men and one woman, 37 to 60 years old, showed total occlusion of this vessel. Four of them had angina pectoris and three had had a myocardial infarction. All five showed deep ST depression in V 2(or 3)-6 during bicycle exercise testing. Apart from the left main artery occlusion, all had significant obstructive lesions in other coronary vessels, including the right coronary artery or its major branches. There was collateral circulation from the right coronary artery in all patients. Left ventricular function was well preserved in three patients and markedly impaired in two. Four patients underwent bypass surgery and they have been followed for 10 to 28 months. Three are free of angina and one has only minimal angina. One patient refused surgery and he continued to have severe angina despite intense medical treatment. He died suddenly after 30 months follow-up. In patients with complete occlusion of the left main coronary artery, development of adequate collateral flow seems important in preserving left ventricular function, but collaterals are usually insufficient to prevent angina. Moreover, associated obstructive lesions in other coronary arteries constitute a potential threat to the collateral circulation. Effective symptomatic relief is obtained by coronary bypass grafting, and revascularization may also improve prognosis in this subset of patients with coronary heart disease.     

Immediate and long-term outcomes of stent implantation for unprotected left main coronary artery disease

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18±3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.     

无保护左主干病变支架置入术预后及影响因素的分析--中国无保护左主干病变支架置入术注册(CHANCE)研究

目的评价无保护左主干(LMCA)病变支架置入术后的即刻及长期预后,并探讨影响预后的因素.方法本研究为多中心注册研究,对国内23家医院在1997年5月至2003年3月间完成的连续择期无保护LMCA病变裸金属支架置入术的患者进行注册登记,全部患者均填写固定表格.结果共224例患者进行了注册,年龄22～88岁,平均(60.1±12.0)岁.有既往心肌梗死史患者53例(23.7%),合并糖尿病45例(20.1%).孤立性无保护LMCA126例(56.2%),LMCA合并其他血管病变98例(43.8%).平均左室射血分数(63.9±12.3)%. 223例(99.6%)LMCA病变支架置入术成功,91例(92.9%)非LMCA病变支架置入术成功.住院期间死亡1例(0.45%),非Q波心肌梗死(MI)1例(0.4%).平均随访(15.6±12.3)个月,死亡12例(5.4%),其中心原性死亡10例(4.5%),非心原性死亡2例(0.9%),急性MI 4例(1.8%), LMCA 靶病变血管重建术26例(11.7%),累积主要心脏不良事件(MACE)36例(16.1%).左室射血分数<40%、女性和LMCA合并多支血管病变增加死亡危险,多支病变非完全血管重建增加MACE发生率;多因素回归分析显示左室射血分数<40%和女性为预测死亡和MACE的独立危险因素.102例(45.7%)患者进行了造影复查,LMCA 再狭窄32例(31.4%).术中有回旋支开口部受累者再狭窄率增加.结论经过选择的无保护LMCA病变支架置入术是可行和安全的,并可取得较好近、远期疗效.目前,无保护LMCA支架置入术应选择孤立性LMCA病变或合并多支病变但能达到完全性血管重建、左室射血分数≥40%的患者或不能行冠状动脉旁路移植术的患者.     

Left main intervention in myocardial infarction

We report an 84‐year‐old patient who suddenly developed nausea, vomiting, hypotension, and needed intubation, assisted ventilation and pharmacological vasopressor support. Admission EKG showed anterior and lateral leads ST segment depression and 2 mm ST segment elevation in avR lead. Angiogram showed unprotected left‐main coronary‐artery (LM) sub‐occlusive disease and totally occluded ostial right‐coronary‐artery (RCA), distally filled through the left‐coronary system. Unprotected LM disease was immediately treated with bare metal stent. The stent jailed the left‐circunflex coronary‐artery (LCx) ostium but did not compromise the arterial flow. Lately, the patient was discharged in a very good health condition. Ten months angiographic follow‐up showed an extremely compromised LCx ostium treated successfully with drug eluted stent (DES) and mid left anterior descendent (LAD) severe lesion, treated with DES. © 2009 Wiley‐Liss, Inc.