Unprotected Left Main InterventionPatient Selection, Operator Technique, and Clinical Outcomes
Paul S. Teirstein, MD1,*
Division of Cardiology and Interventional Cardiology, Scripps Clinic, La Jolla, California.
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Figure 1 Critically Narrowed Midshaft Stenosis in an 83-Year-Old Man With Unstable Angina
This is one of the most straightforward unprotected left main coronary artery lesions for stenting (A). The arrow shows the stenosis. Excellent angiographic outcomes were achieved after implantation of a single 8-mm-long drug-eluting stent, in addition to stenting of the mid left anterior descending artery (B).
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Figure 2 A 54-Year-Old Man With Favorable UPLM Distal Bifurcation Lesion
The lesion involves the distal left main vessel (arrow), but there is very little involvement of the ostium of the circumflex (A). A single stent was deployed from the distal left main vessel into the left anterior descending artery (arrow), crossing over the circumflex artery (the crossover technique). Mild plaque shift into the circumflex was treated with a final kissing balloon inflation, providing an excellent angiographic result (B). UPLM = unprotected left main coronary artery.
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Figure 3 Pre-Procedure Angiogram From a 92-Year-Old Woman With Critical Aortic Stenosis in Preparation for Percutaneous Aortic Valve Implantation
This critically narrowed distal left main lesion (A) involves both the left anterior descending artery and circumflex ostia (arrow). To reduce the risk of closing one of the branch vessels, 2 stents were deployed simultaneously (arrow) using the double-barrel technique (B). The final angiographic result was excellent (C), but this lesion is at higher risk for restenosis, particularly at the circumflex ostium (arrow).
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Figure 4 Recent Meta-Analysis of 1,278 Patients Undergoing UPLM DES From 15 Registries
At a median of 10 months of follow-up, the mortality risk was only 5.5% (range 3.4% to 7.7%). However, there was significant variation between registries, and the follow-up time was relatively short. Data from Biondi-Zoccai et al. (40). CI = confidence interval; DES = drug-eluting stents; UPLM = unprotected left main coronary artery.
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Figure 5 Recent Meta-Analysis of 1,278 Patients Undergoing UPLM DES From 15 Registries
At a median of 10 months of follow-up, the target vessel revascularization (TVR) risk was only 6.5% (range 3.7% to 9.2%). Note the extremely wide variation among the different registries. Data from Biondi-Zoccai et al. (40). Abbreviations as in Figure 4.
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Figure 6 Bifurcation Stenting of a UPLM 5 Months Earlier
Follow-up angiography (left), when viewed in the left anterior oblique and caudal projection, showed the appearance of an important stenosis at the circumflex ostium. However, intravascular ultrasound (right) showed no important stenosis and no neointimal hyperplasia, but instead, an eccentrically expanded stent (arrows). The patient was asymptomatic with a fractional flow reserve after intracoronary adenosine of 0.92. This pseudostenosis in this asymptomatic patient was not treated. Image courtesy of Dr. Antonio Columbo, not previously published. UPLM = unprotected left main coronary artery.
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