Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures

OBJECTIVES: We sought to evaluate immediate and late outcomes after stenting for left main coronary artery (LMCA) stenosis. BACKGROUND: Conventional percutaneous transluminal coronary angioplasty (PTCA), for which coronary artery bypass grafting (CABG) has been the gold standard therapy for years, has yielded poor results in unprotected LMCA lesions. The development of coronary stents, together with their dramatic patency improvement provided by new antiplatelet regimens and their validation against restenosis, warrants a reappraisal of angioplasty in LMCA stenosis. METHODS: From January 1993 to September 1998, 140 consecutive unselected patients with unprotected LMCA stenosis underwent elective stenting. Group I included 47 high-CABG-risk patients, and group II included 93 low-CABG-risk patients. Ticlopidine without aspirin was routinely started at least 72 h before the procedure and continued for one month. Patients were reevaluated monthly. A follow-up angiography was requested after six months. RESULTS: The procedure success rate was 100%. One-month mortality was 9% (4/47) in group I and 0% in group II. A follow-up angiography was obtained in 82% of cases, and target lesion revascularization was required in 17.4%. One-year actuarial survival was 89% in the first 29 group I patients and 97.5% in the first 63 group II patients. CONCLUSIONS: Stenting of unprotected LMCA stenosis provided excellent immediate results, particularly in good CABG candidates. Medium-term results were good, with a restenosis rate of 23%, similar to that seen after stenting at other coronary sites. Stenting deserves to be considered a safe and effective alternative to CABG in institutions performing large numbers of PTCAs.     

Percutaneous coronary intervention for unprotected left main coronary artery stenosis

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.     

One-year clinical outcomes of protected and unprotected left main coronary artery stenting.

AIMS: To evaluate outcomes for left main coronary artery (LMCA) stenting and compare results between protected (left coronary grafted) and unprotected LMCA stenting in the current bare-metal stent era. METHODS: We reviewed outcomes among 142 consecutive patients who underwent protected or unprotected LMCA stenting since 1997. All-cause mortality, myocardial infarction (MI), target-lesion revascularization (TLR), and the combined major adverse clinical event (MACE) rates at one year were computed. RESULTS: Ninety-nine patients (70%) underwent protected and 43 patients (30%) underwent unprotected LMCA stenting. In the unprotected group, 86% were considered poor surgical candidates. Survival at one year was 88% for all patients, TLR 20%, and MACE 32%. At one year, survival was reduced in the unprotected group (72% vs. 95%, P<0.001) and MACE was increased in the unprotected patients (49% vs. 25%, P=0.005). CONCLUSIONS: In the current era, stenting for both protected and unprotected LMCA disease is still associated with high long-term mortality and MACE rates. Stenting for unprotected LMCA disease in a high-risk population should only be considered in the absence of other revascularization options. Further studies are needed to evaluate the role of stenting for unprotected LMCA disease.     

Early recognition of catheter‐induced left main coronary artery vasospasm: Implications for revascularization

Catheter‐induced left main coronary artery (LMCA) vasospasm is a rare complication of coronary angiography that confounds the decision for coronary artery bypass graft (CABG) surgery. We report two cases of catheter‐induced LMCA vasospasm. The first case was a 68‐year‐old woman who presented 6 years after CABG for presumed severe LMCA atherosclerotic disease. Coronary angiography demonstrated totally occluded CABGs and normal native coronary arteries, including a normal LMCA. The second case was a 56‐year‐old man with severe LMCA stenosis, who was scheduled for unprotected LM percutaneous coronary intervention (PCI). Repeat angiography 2 days later showed no stenosis. These cases emphasize the need for meticulous technique and a high index of suspicion of LMCA vasospasm. Intravascular ultrasound (IVUS) at the time of angiography may help to identify minimal atherosclerotic disease suggesting vasospasm. Alternatively, noninvasive testing, such as Computed Tomography (CT) angiography, may diagnose LM spasm in these patients prior to CABG surgery. © 2010 Wiley‐Liss, Inc.     

Comparison of outcomes of unprotected left main versus multivessel coronary artery interventions

Left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has emerged as an appealing alternative to bypass surgery for significant LMCA disease, especially in high-risk candidates. PCI for unprotected LMCA stenosis is currently designated a class IIb indication. Direct comparisons between unprotected LMCA PCI and multivessel PCI are lacking. We aimed to determine the incremental risk associated with unprotected LMCA PCI compared to multivessel PCI. We queried the Cleveland Clinic PCI database to identify patients who underwent unprotected LMCA PCI from 2003 through 2009 and compared these to patients undergoing multivessel PCI in the same period. Patients undergoing PCI for acute myocardial infarction were excluded. Mortality was derived using the Social Security Death Index. Short-term (≤30-day) mortality rates in the LMCA PCI group (n = 468, 1.9%) were similar to the death rate in the multivessel PCI group (n = 1,973, 1.3%, p = 0.3). There was no significant difference in adjusted mortality between the 2 study groups. Stratifying LMCA PCI by the number of concomitant vessel territories treated, there was no significant difference in mortality in any LMCA PCI category (LMCA only, LMCA + 1-vessel PCI, LMCA + multivessel PCI) compared to multivessel PCI. In conclusion, there was comparable short-term and long-term mortality in the LMCA PCI and multivessel PCI groups. LMCA stenting did not appear to incur incremental risk compared to multivessel PCI.     

药物洗脱支架在冠心病无保护左主干病变中的应用

目的评价药物洗脱支架治疗经选择冠心病无保护左主干病变的安全性和有效性。方法2003年1月~2005年6月间,共有48例经选择的冠心病患者,年龄39~81岁,经冠状动脉造影证实为无保护左主干病变(左主干狭窄均≥75%)行介入治疗置入药物洗脱支架。结果48例患者介入治疗均获得成功,共置入药物洗脱支架75枚(51 Cypher,18 Taxus,6 Firebird)。其中左主干开口部狭窄5例(10.4%,5/48),体部狭窄6例(12.5%,6/48),远端分叉部位狭窄37例(77.1%,37/48)。37例远端分叉部位狭窄患者中,主支支架加边支经皮冠状动脉介入治疗(PCI)10例,双支架术27例,最后成功对吻球囊扩张30例(81.1%,30/37)。所有患者治疗后临床症状明显缓解或消失,住院及6个月随访期间无严重心血管事件发生,43例患者术后6个月行冠状动脉造影随访,2例患者再狭窄(均为分叉病变)行冠状动脉旁路移植术(CABG),冠状动脉造影随访率89.6%,再狭窄率4.7%。结论药物洗脱支架介入治疗冠心病无保护左主干病变安全有效,近中期效果良好。     

无保护左主干病变经皮冠状动脉介入治疗的近期和远期疗效

目的　探讨无保护左主干病变 (UPLMT)经皮冠状动脉介入治疗 (PCI)的近、远期疗效。方法　自 1992年 12月至 2 0 0 2年 12月期间 ,对 174例UPLMT行PCI,其中定向斑块旋切术 (DCA) 12 1例 ,支架术 5 3例。其中 85例被列为不能耐受冠状动脉旁路移植术 (CABG)或外科手术高危。术后半年内每月至少门诊复查一次 ,以后定期随诊、电话随访。术后 3、6、12月行冠状动脉造影复查。结果　PCI术均获血管造影成功。住院期间主要不良心脏事件 (MACE) 16例 (9 2 % ) ,15 8例 (90 8% )获操作成功。术后半年随访发现死亡 17例 (9 8% ) ;其中心源性死亡 8例 (4 6 % ) ,均发生于不能耐受CABG或外科手术高危组。半年内有 15 2例患者接受冠状动脉造影复查 ,其中有 36例 (2 3 7% )行血管重建。Kaplan Meier生存分析显示 :PCI术后 1年、3年生存率 (免于死亡 )分别为 89 7%、84 5 % ,术后 1年、3年免于心脏事件的生存率分别为 6 3 8%、5 7 5 %。结论　对UPLMT ,尤其是开口部、体部病变 ,PCI的近期疗效可以接受 ,但术后主要心脏事件 (如血管重建、心肌梗死、死亡等 )有待进一步减少。     

Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry)

Although great interest exists in the relative efficacy of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary artery stenosis, data comparing the 2 strategies are scant. Furthermore, no comparison has ever been performed between CABG and drug-eluting stents in this setting. From January 2002 to June 2005, 154 patients with unprotected left main coronary artery stenosis underwent CABG and 157 underwent PCI. Ninety-four patients received a drug-eluting stent in the left main artery. After a median follow-up of 430 days, the rate of mortality, acute myocardial infarction, and target lesion revascularization was 12.3%, 4.5%, and 2.6%, respectively, in the CABG group and 13.4%, 8.3%, and 25.5%, respectively, in the PCI group (death and myocardial infarction p = NS, target lesion revascularization p = 0.0001). Although patients treated with drug-eluting stents had a 25% relative risk reduction in the rate of death, myocardial infarction, and target lesion revascularization compared with patients treated with bare stents, event-free survival was still better for patients treated with CABG. In the multivariate analysis, age >or=70 years, New York Heart Association classes III and IV, acute coronary syndromes, and peripheral vascular disease were the only independent predictors of mortality. In conclusion, our results have indicated that at long-term follow-up no difference exists in the rate of mortality and myocardial infarction between PCI and CABG for the treatment of unprotected left main coronary artery stenosis. However, the rate of target lesion revascularization was higher in the PCI group.     

The impact of the introduction of drug-eluting stents on the clinical practice of surgical and percutaneous treatment of coronary artery disease.

AIMS: Sirolimus-eluting stents (SES) have recently been shown to reduce restenosis in selected patients. The impact of this new stent on the use of coronary bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in clinical practice is yet unknown. Therefore, we investigated the impact of SES on the clinical practice of CABG and PCI in a series of unselected consecutive patients. METHODS AND RESULTS: Between April and October 2002, a policy of SES implantation for all procedures has been instituted in our hospital. In total, 798 patients were referred to PCI and 275 to CABG (SES group). A control group was composed of all interventions (806 PCI and 314 CABG) performed during the preceding 6 months (pre-SES). The main outcome was the occurrence of major adverse cardiac events (MACE) at 15 months. In the SES era, a significant shift was noted in the PCI group towards more multi-vessel stenting (28 vs. 24%; P<0.05), more bifurcation stenting (18 vs. 7%; P<0.0001), and the use of more stents (1.9 vs. 1.5; P<0.05). In the PCI elective patients, a shift was noted towards more three-vessel disease (pre-SES: 16% vs. SES: 23%; P=0.02). Furthermore, we observed a shift in the CABG group towards more impaired LV function (pre-SES: 34% vs. SES: 41%; P=0.02) and towards more three-vessel disease (pre-SES: 67% vs. SES: 75%; P=0.03). Overall, the cumulative MACE percentages at 1 year after coronary revascularization (PCI and CABG combined) decreased from 16.8 to 13.8% (P=0.03). The cumulative MACE percentages in the pure SES group and the pre-SES bare metal stent group at 12 months were 15.6 and 19.8%, respectively (P<0.01). CONCLUSION: The introduction of the SES has certainly had an impact on the treatment strategy of coronary artery disease (CAD). Increased use of these stents allows more complex coronary anatomy to be treated by PCI, and results in lower repeat revascularization rates.     

Trends in percutaneous versus surgical revascularization of unprotected left main coronary stenosis in the drug-eluting stent era: a report from the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR).

OBJECTIVES: We sought to determine how practice patterns for unprotected left main stenosis have changed with the advent of drug-eluting stents (DES). BACKGROUND: Percutaneous coronary intervention (PCI) of unprotected left main coronary stenosis has been controversial. METHODS: We analyzed data submitted to the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) between January 1, 2002 and December 31, 2004 from 1,276,582 cardiac catheterizations at 417 institutions. Of these, 53,548 (4.2%) had left main stenosis >50% and no prior CABG. After excluding the unrevascularized, the patient sample (N = 32,562) was analyzed for PCI vs. CABG. Data was stratified by year/quarter, bare metal stent vs. DES, elective vs. urgent/emergent situations, LVEF < or > or =40%, and %left main and RCA stenosis. RESULTS: Of unprotected left main revascularizations from 2002 to 2004, PCI increased from 17.0% to 21.9%, while CABG decreased from 83.0% to 78.1% (P < 0.0001). In 2002, bare metal stents were used for all PCIs; in 2004, bare metal stent use was only 25.5%, while DES use was 74.5% (P < 0.0001). Of elective procedures, PCI rose from 19.1% to 27.5% while CABG fell from 80.9% to 72.5% (P < 0.0001). Similar trends, all significant, were seen in every clinical situation. CONCLUSIONS: In the era of DES, the rate of PCI for unprotected left main stenosis has risen, while CABG has declined. These findings are seen across varying clinical situations, including elective procedures. DES have rapidly and largely replaced bare metal stents for PCI of unprotected left mains. However, PCI is still chosen less frequently than CABG for unprotected left main revascularization.     

Angioplasty of the unprotected left main coronary artery stenosis with standby cardiopulmonary support--a case report

Stenosis of the unprotected left main coronary artery (LMCA) is a classical indication for coronary artery bypass graft surgery (CABG). Percutaneous coronary intervention (PCI) of LMCA may be an alternative to surgical treatment if atherosclerosis of distal segments is very advanced. The periprocedural risk is high, especially if comorbidities are present. However, long-term results remain unclear. The ongoing Syntax trial will clarify whether angioplasty of LMCA with drug-eluting stents can be equivalent to CABG. We present a case of a patient with occluded right coronary artery, severe stenoses of the LMCA, left anterior descending artery and left circumflex artery, and poor left ventricular ejection fraction in whom PCI for stenosis of unprotected LMCA with standby cardiopulmonary support was performed.     

Treatment of unprotected left main disease with drug-eluting stents in patients at high risk for coronary artery bypass grafting.

BACKGROUND: Percutaneous coronary intervention (PCI) for high-grade stenosis of the left main coronary artery with bare-metal stents has been limited by restenosis, and most patients are managed with coronary artery bypass grafting (CABG). Recently, drug-eluting stents (DES) have reduced instent restenosis after PCI, but their role in the treatment of left main disease remains unclear. AIMS: The aim of this study was to determine the outcomes after utilizing DES to treat left main disease. METHODS: Twenty consecutive symptomatic patients with >50% angiographic stenosis of the left main coronary artery with no prior history of CABG ["unprotected left main" (ULM)] underwent PCI with DES. Patients were divided into two groups based on the presence (Group A, n=5) or absence (Group B, n=15) of preprocedural cardiogenic shock. At follow up (median, 14 months), cumulative major adverse cardiac events (MACE-death, myocardial infarction, or target vessel revascularization) were determined. RESULTS: Sixteen (80%) of 20 patients were at high risk for CABG because of comorbidity, advanced age, or cardiogenic shock. Procedural success was 100% (20/20). Three of five patients in Group A (60%) died in hospital and the two surviving patients experienced no MACE at follow up. In Group B (n=15), there was no in-hospital MACE, but one patient died suddenly 8 weeks postprocedure [cumulative MACE of 7% (1/15)]. CONCLUSIONS: Our study demonstrates the feasibility of ULM treatment with DES with acceptable medium-term outcomes. While CABG remains the best form of revascularization for the majority of patients with ULM, DES should be considered in those who are at high risk.     

Unprotected Left Main Revascularization in the Setting of Non-coronary Atherosclerosis: Gulf Left Main Registry

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in revascularization of left main coronary artery (LMCA) disease has been evaluated in previous studies. However, there has been minimal study of the relationship between co-existing non-coronary atherosclerosis (NCA) and LMCA disease revascularization. We aim to examine this relationship. The Gulf-LM study is a retrospective analysis of unprotected LMCA revascularization cases undergoing PCI with second generation drug-eluting stent vs CABG across 14 centers within 3 Gulf countries between January 2015 and December 2019. A total of 2138 patients were included, 381 with coexisting NCA and 1757 without. Outcomes examined included major adverse cardiovascular and cerebrovascular events (MACCE), cardiac and non-cardiac death, and all bleeding. In patients with NCA, preexisting myocardial infarction and congestive heart failure were more common, with PCI being the most common revascularization strategy. A statistically significant reduction in in-hospital MACCE and all bleeding was noted in patients with NCA undergoing PCI as compared to CABG. At a median follow-up of 15 months, MACCE and major bleeding outcomes continued to favor the PCI group, though no such difference was identified between revascularization strategies in patients without NCA.In this multicenter retrospective study of patients with and without NCA who require revascularization (PCI and CABG) for unprotected LMCA disease, PCI demonstrated a better clinical outcome in MACCE both in-hospital and during the short-term follow-up in patients with NCA. However, no such difference was observed in patients without NCA.     

老年人无保护左主干病变经桡动脉途径介入治疗

目的探讨经桡动脉途径PCI在老年人无保护左主干病变(UPLMT)中的疗效和安全性。方法65岁以上的UPLMT患者28例择期行PCI,其中开口部6例,体部4例,分叉部18例,所有患者均置入药物洗脱支架。术后每半个月或1个月门诊复查1次,其中19例患者3～6个月行冠状动脉造影复查。结果28例患者PCI均取得成功,术后达TIMI3级血流,住院期间主要不良心脏事件1例,冠状动脉造影复查显示,支架内再狭窄1例(5.3%),再次行PCI。术后平均随访(18.6±2.7)个月,随访1年内无死亡。结论选择性经桡动脉老年UPLMT患者行PCI即刻成功率高,其近中期疗效可以被接受。     

经桡动脉行无保护左主干病变介入治疗

目的:回顾性总结29例冠状动脉造影发现为无保护左主干开口及体部狭窄病例的冠脉介入治疗(PCI)资料,以探讨手术的安全性和可行性。方法:术前给予常规药物治疗,经桡动脉途径行PCI,观察桡动脉穿刺成功率、PCI即刻成功率、手术时间、支架扩张时间和扩张压力、住院期间严重并发症发生率、出院前心绞痛发作情况评估及术前心电图(ECG)特点分析。结果:29例患者桡动脉穿刺成功率和PCI即刻成功率均为100%,手术时间25～50(38±8)min,支架扩张时间3～7(5±1.3)s,支架扩张压力14～20(16.0±1.9)atm(1atm=101.325kPa),住院期间无严重并发症发生,前臂肿胀3例,术后心绞痛显著缓解。术前胸痛发作时ECG特点:典型"左主干"心电图17例,胸前导联ST-T改变者10例,间歇性左束支阻滞2例。结论:经桡动脉途径对无保护左主干开口和体部病变行PCI治疗,成功率高,安全有效。     

Treatment of Patients with Left Main Coronary Artery Disease

Considering lesion priority and its clinical consequences, coronary artery bypass grafting (CABG) has been a treatment of choice for revascularization in patients with significant left main coronary artery (LMCA) disease, However, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with stenting has emerged to be a less invasive and feasible revascularization treatment for these patients. The cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction, and stroke are similar among PCI and CABG, with the only difference being the rate of repeat revascularization. Based on these data, the current guideline of revascularization of LMCA disease has adopted an increasing off-label experience with stenting and clinical studies and been updated to partly approve PCI as a viable alternative (in level of class IIb) in selected patients. The choice of PCI or CABG for unprotected LMCA disease depends on several clinical and anatomic features, ensuring crucial patient selection to be a cornerstone for achieving favorable long-term outcomes. In patients with very complex anatomic features and concomitant diffuse multivessel disease, CABG is preferred so as to avoid procedural and future thrombotic risks and to provide more complete revascularization. By contrast, in patients with relatively simple LMCA disease, such as ostial/shaft LMCA disease, isolated LMCA disease (with or without one or two-vessel involvement), and LMCA disease with low SYNTAX score, PCI is an alternative, and in some cases a preferred, strategy to reduce surgical risks (eg, stroke and in-hospital events following major surgery). For the future, ongoing large clinical trials might also boost interventional cardiologists to select PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease. This evidence will most likely change the current clinical practice and guidelines of optimal revascularization strategy for unprotected LMCA disease.     

Long-term effect of stenting in unprotected left main coronary artery disease in the elderly

Objective To evaluate the feasibility, safety and efficacy of percutaneous stent implantation for treating left main coronary artery (LMCA) stenosis. Methods Consecutive patients with unprotected left main coronary artery disease treated by stent-based percutaneous intervention (PCI) at 6 medical centers in China were enrolled. Procedural data and clinical outcomes were obtained from all patients. Results From January 2001 to December 2004, 138 patients (79 males and 59 females; mean age: 69.7±5.8 years) underwent PCI for LMCA stenosis. Bare metal stents (BMS) were implanted in 51 patients with non-bifurcational lesions and in 5 patients with bifurcational lesions from January of 2001 to June of 2003 (BMS group);. drug eluting stents (DES) were used unselectively to cover both bifurcational and non-bifurcational lesions in 86 patients from July of 2003 to December of 2004 (DES group). Procedural success rate of the 138 cases was 98% (135/138). One patient (0.7%) with bifurcation lesion who was treated with DES died from severe heart failure 2 weeks after the procedure. During a mean follow up period of 21.3±5.6 months, one patient died from renal failure, one from sudden cardiac death, 4 underwent target lesion revascularization (TLR) in the BMS group, which all occurred in patients with bifurcational lesions; whereas in the DES group no deaths occurred and only one patient with bifurcational lesion had TLR. Conclusions (1) PCI is feasible and relatively safe to treat unprotected left main coronary artery disease in elderly patients at medical centers with experienced professionals. (2) BMS and DES have similar immediate and long-term efficacy in the treatment of ostium and shaft lesions of the LMCA. (3) DES are strongly suggested in the therapy of distal bifurcation lesion of unprotected LMCA.     

Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.

OBJECTIVES: This study evaluated the clinical outcomes of consecutive, selected patients treated with coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main coronary artery (ULMCA) disease. BACKGROUND: Although recent data suggest that PCI with DES provides better clinical outcomes compared to bare-metal stenting for ULMCA disease, there is a paucity of data comparing PCI with DES to CABG. METHODS: Since April 2003, when DES first became available at our institution, 123 patients underwent CABG, and 50 patients underwent PCI with DES for ULMCA disease. RESULTS: High-risk patients (Parsonnet score >15) comprised 46% of the CABG group and 64% of the PCI group (p = 0.04). The 30-day major adverse cardiac and cerebrovascular event (MACCE) rate for CABG and PCI was 17% and 2% (p < 0.01), respectively. The mean follow-up was 6.7 +/- 6.2 months in the CABG group and 5.6 +/- 3.9 months in the PCI group (p = 0.26). The estimated MACCE-free survival at six months and one year was 83% and 75% in the CABG group versus 89% and 83% in the PCI group (p = 0.20). By multivariable Cox regression, Parsonnet score, diabetes, and CABG were independent predictors of MACCE. CONCLUSIONS: Despite a higher percentage of high-risk patients, PCI with DES for ULMCA disease was not associated with an increase in immediate or medium-term complications compared with CABG. Our data suggest that a randomized comparison between the two revascularization strategies for ULMCA may be warranted.     

Unprotected left main stenting,short- and long-term outcomes

Abstract

Background: Coronary bypass surgery is recommended for the treatment of left main coronary stenosis. Recently a percutaneous approach has been described as a feasible option. Objectives: To present the in-hospital and long-term clinical and angiographic outcome of a consecutive group of patients undergoing stenting for unprotected left main coronary artery (LMCA) disease, and to compare the clinical and angiographic outcomes of drug-eluting stent (DES) versus metal stent (BMS). Methods: 238 consecutive patients underwent unprotected LMCA stenting. 165 received BMS and 73 received DES. Most patients (88.7%) presented with acute coronary syndrome. Clinical (100%) and angiographic (84%) follow-up was obtained. Results: Patients’ presentation: STEMI (7.2%), non-STEMI (13.5%), unstable angina (67.6%), stable angina (11.7%). Procedural success rate was 100%. In-hospital mortality was 2.1%, all in patients presented with unstable hemodynamic conditions. None of the patients needed emergent CABG. In the long-term follow-up (average three years) there were 12 deaths (5%), 3 patients required CABG and 25 patients required TVR. The overall angiographic LM restenosis rate show a trend toward lower rate in the DES group than the BMS group (9.6% versus 13.8%, P = 0.08). There was no difference in one year mortality (4.1% versus 4.2%) and AMI (2.7% versus 2.8%) between DES and BMS. Conclusions: Stenting for LM stenosis can be performed safely with acceptable in hospital and long-term outcome. Reconsideration of current guidelines should be considered. Drug-eluting stent implantation for unprotected LMCA stenosis appears safe with regard to acute and long-term complications and is more effective in preventing restenosis compared to BMS implantation.     

Endeavor支架治疗冠心病左主干病变的临床疗效观察

目的:评价Endeavor支架治疗选择性冠心病无保护左主干病变的安全性和有效性。方法:2006年9月至2008年1月,共84例经选择的冠心病无保护左主干病变患者,年龄37～78岁,平均(59.6±14)岁,其中男性60例(71%),有糖尿病者24(29%),左主干狭窄均≥75%,均接受Endeavor支架治疗,随访12个月,随访终点指标:不良心脏事件(MACE)率、靶血管重建(TVR)率,支架血栓发生率。结果:84例患者介入治疗均获得成功,共植入Endeavor支架148枚。其中左主干开口部狭窄8例(10.4%,8/84),体部狭窄12例(12.5%,12/84),远端分叉部位狭窄64例(76.2%,64/84)。64例远端分叉部位狭窄患者均使用分步Crush技术处理主支和边支。所有患者治疗后临床症状明显缓解或消失,12个月MACE率为7.1%,TVR率为7.1%,支架血栓发生率为0%。结论:Endeavor支架介入治疗冠心病无保护左主干病变安全有效,近期效果良好。